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OPERATIVE DENTISTRY. 



STANDARD WORKS ON DENTISTRY 

PUBLISHED BY 

P. BLAKISTON, SON & CO. 



HARRIS, THE PRINCIPLES AND PRACTICE OF DENTISTRY. 

Tenth Revised Edition, with over 400 Illustrations. Octavo. Price, Cloth, $6.50. 

Leather $7.00. 

HARRIS, A DICTIONARY OF MEDICAL TERMINOLOGY, 
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TAFT'S OPERATIVE DENTISTRY. A Practical Treatise, Fourth Revised 
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$5.00. 

RICHARDSON'S MECHANICAL DENTISTRY. Third Enlarged and 
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$4.75. 

TOMES, DENTAL ANATOMY, HUMAN AND COMPARATIVE. 

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TOMES, SYSTEM OF DENTAL SURGERY. Second Edition, with 263 
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HANDY, TEXT-BOOK OF HUMAN ANATOMY. With 264 Illustra- 
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COLE'S DENTAL MECHANICS. A Practical Manual. Second Edition, with 

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FLAGG, PLASTICS AND PLASTIC FILLING. Numerous Illustra- 
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WEDT.'S PATHOLOGY OF THE TEETH. With Special Reference to 
their Anatomy and Physiology, with 105 Illustrations. Octavo. Price, Cloth, $4.50. 
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STOCKEN, DENTAL MATERIA MEDICA AND THERAPEU- 
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LEBER & R r >TTENSTEIN, DENTAL CARIES AND ITS 

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HUNTER, PRACTICAL MECHANICAL DENTISTRY. With 100 
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SEWELL, DENTAL ANATOMY AND SURGERY. With 77 Illustra- 
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"WHITE ON THE MOUTH AND TEETH. 24 Illustrations. Price, Paper 

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*>.* Catalogue of Dental Books furnished upon application. 



PRACTICAL TREATISE 



OPERATIVE DENTISTRY 



J. TAFT, M.D., D.D.S., 

PROFESSOR OF PRINCIPLES AND PRACTICE OF OPERATIVE DENTISTRY IN THE 

DENTAL COLLEGE OF THE UNIVERSITY OF MICHIGAN, 

RECENTLY PROFESSOR OF OPERATIVE DENTISTRY AND DENTAL HYGIENE IN 

THE OHIO COLLEGE OF DENTAL SURGERY. 



FOURTH EDITION, REVISED, 



ONE HUNDKED AND THIKTY-SIX ILLUSTEATIONS. 



L 



PHILADELPHIA: 

P. BLAKISTON, SON & CO., 

10 12 Walnut Street. 
188 3. 






Entered, according to Act of Congress, in the year 1882, 

By P. BLAKISTON, SON & CO., 
In the office of the Librarian of Congress, at Washington. 



PREFACE. 
FOUETH EDITION. 



In the preparation of the Fourth Edition of this 
work, the changes have perhaps not been so great as 
those in the third ; yet the labor has involved a great 
deal of care and attention. 

There has seemed no reason for changing the gen- 
eral plan of the work. The aim from the beginning 
has been to present the subjects embraced in such an 
order as will best serve the interest of the student, 
for whom the work is primarily intended. 

It has been in many instances a somewhat difficult 
task to decide as to the rejection of some methods, 
instruments and appliances. It is not always easy 
to determine upon the merits of the new as compared 
with the old and tried. Caution and perhaps wisdom 
dictates that those things that have been thoroughly 
tested and approved, should uot be hastily thrown 
aside for those of recent production, without good 
evidence of improvement. 



VI PREFACE— FOURTH EDITION. 

Within the last five years quite as large a number 
of new appliances and instruments have been brought 
forth, as in any equal period before, but it yet remains 
to be proven how many of them are better than those 
in use up to that time. A few doubtless are, and the 
aim has been to include all these in the present 
edition. Quite a number of instruments and appli- 
ances that have been manifestly superseded, have 
been dropped from the work, and only those retained 
that are valuable and efficient. 

Cincinnati, November, 1882. 



PREFACE. 
THIRD EDITION. 



So great have been the changes, in almost every 
branch of Dental Practice, since the publication of 
the second edition of this work, that the labor in- 
volved in the preparation of a new one has been little 
less than the writing of an entirely new work. 

During the last few years many new instruments, 
appliances and modes of practice, have been intro- 
duced, that have proved very valuable, and are in 
use by the profession, superseding in many cases 
others less efficient, while others, again, have become 
wholly obsolete or comparatively worthless. It has 
therefore become necessary to omit many illustrations 
with descriptions of them, but so many more have 
been added that are now regarded as desirable and of 
great practical value, as to greatly increase the whole 
number. 

The general scope and plan of the work has not 
been changed, or any material modification made, 



Vlll PKEFACE — THIRD EDITION. 

except adapting it more fully to the present advanced 
state of the science. An Appendix has been added, 
presenting some subjects more fully than could be 
satisfactorily done in the body of the work. 

The author, in conclusion, cannot refrain from 
expressing the hope that this edition will be as favor- 
ably received as the previous ones, and prove in- 
strumental in promoting the best interests of the 
profession. 

Cincinnati, January, 1877. 



PREFACE. 
SECOND EDITION. 



The preparation of the present edition of this work 
has been attended with more labor and effort than 
the author had anticipated. ' 

The first edition, at the time of its writing, was 
designed to embody and present the principles and 
practice of the profession in the operative depart- 
ment, in its highest attainment. 

Since that time, however, so great have been the 
changes in many points of practice and application 
of principles, that those given as the best, nine years 
ago, are superseded by others and out of use ; so that 
in many particulars the labor has been almost equal 
to the preparation of new matter. 

The object in this, as in the former edition, has 
been to bring the work up to the present status of the 
profession ; and though it has been accomplished 
with many misgivings and consciousness of defects, 
the author is not without hope that it may be of value 
to those preparing to enter the profession, if not to 
those already in it. 



CONTENTS. 



CHAPTEE I 



Introduction, . 
Deposits, 
Tartar, 

Its Origin, 

Points of Deposit, 

Its Effects, 

Method of Removing it, 
Green Tartar, . 

Its Origin, 

Treatment, 
Irregularity, 

Effects, . 
Atrophy, . 

The Cause, 

Effects, 
Exostosis, 

Its Effects, . 

The Cause, 
Denuding, 
Chemical Abrasion, . 

The Cause, . 
Necrosis of the Teeth, 

Causes, 



CHAPTER II 



Caries of the Teeth, 

Predisposing Causes of Caries, . 
Exciting Causes of Caries, 
Comparative Liability to Decay, 
Consequences of Caries, 
Treatment of Caries, 



PAGE 

17 
18 
18 
19 
20 
22 
23 
25 
26 
28 
28 
30 
30 
32 
33 
33 
35 
35 
36 
38 
39 
40 
42 



43 



57 
64 
66 

6S 



Xll CONTENTS. 




CHAPTEE III. 






PAGE 


General Remarks on Filling, 


74 


Materials for Filling, . . . . 


.78 


Indestructibility, 


78 


Adaptability, .... 


79 


Hardness, .... 


79 


Non-conductor, .... 


79 


Cohesion, .... 


80 


Color, 


81 


Lead, ..... 


81 


Tin, 


82 


Silver, . . . 


84 


Platinum, 


85 


Gold, 


86 


Various Preparations of Gold, 


88 


Crystal Gold, .... 


89 


Amalgam, ..... 


91 


Oxychloride of Zinc, 


94 


Oxyphosphate of Zinc, 


95 


Non-metallic Materials, . 


95 


Hill's Stopping, .... 


96 



CHAPTER IV. 




Instruments for Filling, ..... 


99 


Heavy Cutting-instruments, 


99 


Drills, 


101 


Bur Drills, ..... 


101 


Common Drills, ..... 


104 


Drill Stocks, ..... 


106 


Excavators, ...... 


114 


Of the Manufacture of Excavators, . 


119 


Filling Instruments, ..... 


121 


The File, 


134 


The Use of the File, .... 


137 


Mode of Using the File, 


137 



CHAPTER V. 



Separation of the Teeth, 



142 



CONTENTS. 


xiii 


CHAPTEE VI. 






PAGE 


Filling Teeth, 


154 


Examination, . . . . 


155 


Opening Cavities, 


158 


Removal of Decay, . . 


160 


Forming Cavities, ..... 


164 


Exclusion of Moisture, ..... 


172 


Saliva Pump, ..... 


175 


Silk Thread, ...... 


179 


Clamps, ...... 


179 


Elastic Strap, ....... 


182 


Wedges, ...... 


183 


Jarvis's Separators, ..... 


184 


Chip Blower, ..... 


188 


Introducing the Filling, ..... 


189 


Cylinder or Block Filling, .... 


194 


Forming Blocks, ...... 


195 


Introducing the Blocks, .... 


198 


Pellets, . 


201 


Cohesive Foil, ...... 


202 


The Mallet, . . . . . . 


206 


Crystal or Sponge Gold, ..... 


209 


Finishing Fillings, 


213 


CHAPTER VII. 




Classification of Decayed. Cavities, 


217 


Filling by Classes and Modifications, 


219 


First Class, ...... 


219 


Saliva Pump, ..... 


225 


Filling with Foil, . 


227 


Cohesive Foil, ..... 


229 


Crystal Gold, ...... 


231 


Second Class, ...... 


234 


Third Class, ...... 


237 


Fourth Class, ...... 


242 


Fifth Class, ....... 


253 


Special Cases, ..... 


259 


The Palatal portion of the Crown broken away, leav- 




ing the outer portions standing — pulp not exposed, 


260 


Screws for Securing Fillings, 


264 


Filling large Cavities on the Labial Surfaces of the 




Superior Ineisors, . 


265 


Porcelain Cavity Stoppers, .... 


267 



XIV 



CONTENTS. 



CHAPTEK VIII. 





PAGE 


Pathological Conditions, .... 


270 


Sensitive Dentine, ..... 


271 


Treatment of Inflamed Dentine, 


274 


Tannin or Tannic Acid, 


277 


Creosote, or Carbolic Acid, 


278 


Nitrate of Silver, .... 


278 


Chloride of Zinc, 


280 


Terchloride of Gold, 


281 


Arsenious Acid, 


281 


Alkaline Caustics, .... 


284 


CHAPTEE IX. 




Exposed Pulps, ..... 


287 


Treatment of Exposed Pulps, 


289 


Destruction of the Pulp, 


302 


Actual Cautery, . . . 


307 


Potential Cautery, .... 


" 308 


Arsenious Acid, ..... 


308 


Application, .... 


310 


Filling Pulp-cavities and Canals, 


315 


Preparing the Teeth and Hoots for Filling, 


322 


Dental Periostitis, ..... 


331 


Treatment, ..... 


335 


Alveolar Abscess, . . ... 


339 


Treatment, . . 


344 


CHAPTER X. 




Pivot Teeth, ...... 


353 


Fitting the Crown, .... 


357 


Attachment of the Crown, 


359 


Metallic Pivots, . ... 


363 


CHAPTEK XI. 





Extraction of Teeth, 
General Remarks, 
Indications for Extraction, 
Extracting Instruments, . 
The Key, 



374 
376 
380 
383 
384 



CONTENTS. 



XV 







PAGE 


Forceps, . 




388 


Elevators, 




400 


Hooks, 




401 


Screw, . 




401 


Gum-lancet, 




403 


The Method of Lancing the 


Gums, .... 


404 


Extraction of the Teeth, . 




406 


Superior Incisors, 




406 


Superior Cuspids, 




408 


Superior Bicuspids, 




409 


Superior Molars, 




412 


Extraction of Roots, 




414 


Superior Third Molars, 




415 


Inferior Incisors, . 




418 


Inferior Cuspids, 




419 


Inferior Bicuspids, 




420 


Inferior Molars, 




421 


Inferior Third Molars, 




425 


Extraction preparatory to the Insertion of Artificial Dentures 


426 


Conditions to be observed in 


Extraction, 


428 



CHAPTER XII. 



Accidents in the Extraction of Teeth, 


433 


Hemorrhage, ..... 


434 


Treatment, ..... 


443 


Fracture of the Alveolus, 


444 


Laceration of the Gums, .... 


446 


Breaking the Teeth, .... 


447 


Removal of a Wrong Tooth, 


448 


Dislocation of the Inferior Maxilla, . 


450 


Syncope, ...... 


452 



CHAPTER XIII. 



Anaesthetics, 

Chloroform — Ether, 
Nitrous Oxide, 
Local Anaesthesia, 

Congelation, 
Extraction by Electro-magnetism, 

Application, 



455 
455 
457 
459 
462 
465 
467 



XVI 



CONTENTS. 



APPENDIX. 

Section A. — Dental Caries, .... 

" B. — Dr. Corydon Palmer's Plugging Instruments, 
" C— Mallets, 

Electric Mallet, 

Automatic Plugger for Engine, . 
" D. — Matrices for Proximal Fillings, 



PAGE 

469 
480 
488 
491 
494 
495 




I I 

A 

OPERATIVE DENTISTRY. 




CHAPTER I. 



INTRODUCTION. 



Introductory to the following treatise, some con- 
sideration of those conditions and diseases of the teeth 
which require the aid of the dental surgeon seems 
appropriate. To refer, however, to all of these, or to 
remark at length upon any of them, is not consistent 
with the design of this work, or necessary to a proper 
understanding of the subjects proposed. Only those 
affections which pertain to the teeth directly, and the 
contiguous parts, will here be considered ; and the 
latter only so far, in the main, as surgical treatment 
is concerned. Nor will the pathology of contiguous 
parts be introduced ; for the treatment of these being 
mainly therapeutic, rather than surgical, would in- 
volve a discussion of questions not within the scope 
of the present volume. Indeed, it is proposed merely 
to speak of those affections of the teeth which gener- 
ally suggest surgical remedies, and which are impli- 

2 



18 INTRODUCTION. 

cated more or less in the operations described in the 
following pages ; and first, of 

Deposits. 

In this term are included those calcareous forma- 
tions commonly called tartar, a certain coloring mat- 
ter denominated green or brown stain, and such other 
impurities on the teeth as result from neglect, the 
use of tobacco, and like causes. The word 

Tartar 

implies all calcareous deposits upon the teeth. Of 
this substance there are several varieties, the more 
obvious of which have respect to color, composition, 
and consistence. In color, there are all shades, 
from a white, with slight yellow tint, to a jet black; 
and in consistence, all degrees, from a thick, gummy 
mucus to nearly the density of the dentine itself. The 
color will, in most cases, be indicative of the density, 
the lightest shade corresponding with the softest, and 
the darkest with the hardest consistence ; there will, 
however, be found some variation in this respect. 
The tenacity to the teeth is also in proportion to the 
density, the dense and dark adhering most firmly. 
The character of the surface of the tooth upon which 
the deposit is made somewhat modifies the firmness 



TARTAR. 19 

of attachment. The density of the deposit, too, is 
generally indicative of the rapidity of its formation, 
being in an inverse ratio to this. 

All the varieties of tartar are composed largely of 
the same materials ; though the proportions vary 
much in different cases — phosphate and carbonate of 
lime, fibrin, fat, and animal matter, being contained 
in them all. The fact that some varieties are soluble 
in acids, and others not, has been adduced to prove 
that they are entirely different in their composition. 
This, however, is accounted for on another hypothesis : 
in the softer varieties the phosphate of lime is so pro- 
tected by the fat and the animal matter that, under 
ordinary circumstances, acid cannot come in contact 
with it ; but the dense varieties are very soluble, be- 
cause the acid readily comes in contact with the cal- 
careous material. 

Its Origin. — The calcareous constituents of tartar 
are brought into the mouth in a state of solution in 
the saliva, being secreted from the blood with that 
fluid ; while fats and other animal matter are accu- 
mulated from food, waste from the surface of the mu- 
cous membrane, and other residual matter from the 
mucus, and perhaps the saliva as well. 

This calcareous material, which consists chiefly of 
phosphate and carbonate of lime, is precipitated from 
the saliva by the presence, influence, and operation 
of several agencies. 



20 INTRODUCTION. 

J/ The saliva, immediately after passing from the 
ducts into the mouth, undergoes a change by absorp- 
tion of oxygen ; intermingling with mucus and va- 
rious foreign matters in the oral cavity, and variations 
of temperature, that greatly diminish its solvent power 
for the earthy salts referred to. Precipitation now 
takes place, and lodgment is made upon the most sus- 
ceptible body and point presented. 

Normal saliva always holds in solution more or less 
of this material ; and sometimes the agencies above 
referred to are not sufficient to reduce its solvent 
power to the point of precipitation, or letting go the 
material held in solution. It is very probable that in 
some cases the saliva, very soon after being projected 
into the mouth, undergoes change, independent of 
the causes of which mention has been made, quite 
sufficient to permit precipitation of the salts of lime 
it contains. 

Persons of a lymphatic temperament, or a tendency 
toward it, with muscles of a soft, flabby texture, hair 
light, teeth of a rather inferior quality, and a free flow 
of saliva, are most subject to the accumulation of 
tartar; yet there are conditions of almost all consti- 
tutions in which it is freely formed. That it is pre- 
cipitated from the saliva is a fact so easily demon- 
strated and so generally admitted that it need not 
here be considered. 

Points of Deposit. — The points at which salivary 



TARTAR. 21 

calculus is deposited in the greatest quantities upon 
the teeth are in the vicinity of the orifices of the sali- 
vary ducts ; and hence it is found most abundant on 
the lingual surfaces of the inferior anterior teeth, and 
on the buccal surfaces of the superior molars. Fre- 
quently, also, it collects in considerable quantities 
upon the external surfaces of the inferior front teeth. 
The points to which it most readily attaches are at 
the necks of the teeth, immediately beneath the free 
margin of the gum, and at the termination of the 
enamel where it is thickest. A nucleus once formed, 
it encroaches upon the crown of the tooth, if no means 
are employed to prevent its lodgment, at a rate deter- 
mined by the condition of the saliva and the changes 
to which it is subject, and the amount of calcareous 
material in it. 

It is deposited first and most abundantly on the 
necks of the teeth, because here the saliva first comes 
in contact with these organs, and here remains for 
the longest periods and in the largest quantities. That 
it is precipitated very soon after the saliva enters the 
mouth, is evident from the fact that it is found col- 
lected upon the superior molars, just in the vicinity 
of the orifices of the ducts of Steno, where the saliva 
cannot be retained for any considerable time, by 
reason of the position, but must very soon pass along 
upon the surfaces of the contiguous teeth, on which 
it is generally found deposited in much smaller quan- 



22 INTRODUCTION. 

tities. Such is the condition of the saliva sometimes, 
either from being surcharged with the calcareous ma- 
terial, or from weakness of solvent power, that pre- 
cipitation takes place before discharge of the saliva 
from the ducts; and so masses of the solid sub- 
stance have been found in the duct passages, and 
in a few instances have been found imbedded in 
the salivary glands. Tumors are thus sometimes 
found that seem involved in great obscurity,, and 
occasion intense and prolonged suffering. 

Its Effects. — It exercises no directly injurious in- 
fluence upon the substance of the teeth, but it is 
highly prejudicial to the parts immediately in con- 
nection with them, and upon which they depend for 
support. It encroaches upon the gums and alveoli, 
and causes absorption of these important tissues ; 
and as they become destroyed, its encroachments are 
continued and accelerated. In some constitutions 
this process goes on with little or no annoyance to 
the patient, while in others, irritation, inflammation, 
and even suppuration of the gums occur; and thus 
their destruction is effected in a twofold manner. This 
irritation and inflammation may extend to the mu- 
cous membrane, and involve all the adjacent parts. 
The dental periosteum will usually become impli- 
cated ; periostitis will ensue, and often suppuration, 
thus breaking up the attachments of the teeth even 
before the surroundings are removed. The alveolus, 



TARTAE. 23 

too, becomes diseased, and in some instances its 
death and exfoliation result. Salivary calculus, 
however, never induces caries of the teeth, nor even 
favors it. except by inducing disease in the surround- 
ing parts. On the contrary, we frequently meet with 
instances of decay entirely arrested and deposit of 
tartar in the cavity. 

Persons of all ages are subject to this affection ; 
those past middle life being most so, and those ad- 
vanced in years sometimes bavins: teeth nearly cov- 
ered with tartar, as is shown in the accompanying 



Fig. 1, 




illustration. Occasionally, to such an extent do the 
roots become invested with it that the teeth drop 
from the sockets. There are some constitutions 
whose diathesis is favorable to a deposition of sali- 
vary calculus through life. Others, again, will be 
entirely exempt from it till some peculiar constitu- 
tional change intervenes, when it will begin to be 
rapidly produced. 

Method of Removing it. — The removal of salivary 
calculus is an operation that does not involve a great 



24 



INTRODUCTION. 
Fig. 2. 



fl 



amount of skill, but, with suitable ap- 
pliances, is easily performed. There are 
two methods of effecting it; the one, that 
of scaling and scraping, and the other, 
that of decomposing the deposit by the 
application of an acid. The former is 
always to be preferred ; for, in the latter, 
the chemical action of the acid may not 
stop with decomposition of the deposit, 
but by the same affinity, and nearly as 
readily, attacks the tooth itself. For the 
removal of tartar instruments of various 
forms and curves will be necessary, 
adapted and adjusted to the various 
shapes and situations of the surfaces to 
be operated upon. The most common 
forms are represented in the accompany- 
ing figure. The blade of the instrument 
should be applied at a slightly obtuse 



GREEN TARTAR. 25 

angle with the surface of the tooth, just beyond the 
edge of the deposit next to or beneath the gum, and 
thus passed under the tartar, scaling it off to the 
point in such a manner as not to cut or abrade the 
enamel. Deposits of this substance on proximate 
surfaces of the teeth are to be carefully observed, 
and removed with instruments of attenuated blades. 
When the thick incrustations have been thus re- 
moved, the surface should, then be gently scraped, 
so as entirely to clean off all remaining portions, 
and afterward thoroughly polished with fine pumice, 
Arkansas, or rotten-stone, and finished by burnish- 
ing. During the operation frequent employment of 
the brush with water will be required, to cleanse the 
mouth of the detached material and the increased 
secretions ; and, in general, the completion of the 
process will occupy more than one sitting. Since 
this deposit often extends beneath the free margin 
of the gum, much care is necessary to see that it is 
all removed. 

Green Tartar. 

This deposit has been so referred to by writers, as 
to convey the impression that it is of the same gen- 
eric character as salivary calculus. Such a misap- 
prehension is hardly pardonable. The teeth of young 
persons only are subject to this affection, it being 
often found on those of children three or four years 



26 



INTBODUCTION. 



old ; appears on the labial surfaces of the superior 
front teeth, and in largest quantity near the mar- 
gin of the gum. It is seldom seen on the inferior 
teeth, and only on the anterior surfaces of the su- 
perior. The color of this deposit varies from a light 
brown to very dark, inclining to green. Wherever 
present, the surfaces of the teeth are abraded, and 
when it is of long standing, the entire enamel be- 
neath it is destroyed, and the dentine is gradually 
involved in the dissolution. This effect upon the 
teeth is not produced by the coloring matter observed 
upon them, but by an acid in combination with this 
material before it is deposited. The stain is a pre- 
cipitate from this compound, and the acid, leaving 
this, combines with the calcareous ingredients of the 
teeth, to their detriment as above ; but the precipi- 
tate is entirely innocent, so far as decomposition of 
the teeth is concerned. 

Its Origin. — Green tartar, or stain, doubtless has 
its origin in the mucus, when this is in a particularly 
acid condition. That it does not proceed from the 
saliva is proved by the fact that it is never found 
where there is a free flow of saliva, or where it has 
free access ; but the point of its deposit is where the 
saliva is less frequently present, being most abun- 
dant in cases in which there is a large relative 
amount of mucus, and this in a very acid condition. 
But the query might arise here, if the mucus of the 



GREEN TARTAR. 27 

mouth were wholly in that condition, why would not 
the teeth suffer from it elsewhere ? Because, on the 
masticating surfaces of the teeth the friction of the 
food will prevent it, and on the inner surfaces the 
friction of the tongue ; besides, wherever there is a 
free flow of saliva, this will have a counteracting ef- 
fect. Decay goes on very rapidly, after it has once 
commenced, upon teeth affected by this deposit. 

There are points of dissimilarity between this 
green pigment or stain and salivary calculus, that it 
may be well to notice. The latter is from the saliva; 
the former from the mucus ; and hence the one exists 
where there is an abundant flow of saliva, and the 
other where the relative quantity of this is small. 
The calculus is deposited when the saliva is in an 
alkaline condition ; the stain, when the mucus is very 
acid. The former is deposited in large quantities 
and thick incrustations, and upon the surfaces of the 
teeth, and is easily removed without detriment to 
their substance ; whereas the latter is a thin film, 
barely sufficient to stain the surface, and yet it 
erodes the enamel, and cannot be removed without 
detaching some portion of the latter. The one seems 
rather preventive of caries, which does not occur 
beneath it; but the other is highly promotive of 
decay. With these marked features of difference, it 
is surprising that the two should ever have been 
confounded, since it is so important that the distiuc- 



28 INTRODUCTION. 

tive character of each be understood, in order to its 
correct treatment. 

Treatment. — In order to a perfect and final remedy 
for green stain, systemic treatment must be combined 
with the operative and topical ; but only the latter 
will be here described, which has for its object the 
removal of the deposit, and the rendering of the 
eroded surface smooth and polished. There are two 
or three methods of accomplishing this object. When 
the erosion is but slight, it can be effected with 
Hindostan or Arkansas-stone, or pulverized pumice 
and water, applied with a w r ooden polisher of the 
proper form till the stain disappears, and then polish 
with rotten-stone. But when the erosion is too 
extensive to be thus reduced, it must be cut down 
with a corundum wheel or cone, and then finished 
with stone as before. And when the erosion is 
extreme, a cutting-instrument may properly precede 
the corundum. 

Irregularity. 

By this term is implied those variations from a 
beautiful and natural position in which the teeth are 
so frequently found. The principal cause of irregu- 
larity is a disproportion between the size of the arch 
and the space required for the accommodation of the 
teeth. When this disproportion exists, the teeth 
which are first erupted usually occupy very nearly 






IRREGULARITY. 29 

their proper position : bat those which come after- 
ward are more or less disarranged, in proportion to 
the pre-occupation of the space. There are cases in 
which the roots of the temporary teeth are not 
absorbed, and the permanent teeth are erupted out of 
their true position, even when there is room enough 
for them were the former removed. Irregularity is 
mainly confined to the ten anterior teeth of each 
jaw, and usually to the six front teeth, and consists 
in either an inward or an outward inclination, and 
in some instances both. Sometimes the incisors are 
turned in the socket, so that the edge stands at a 
very considerable angle with the proper position. 

The upper teeth are oftener materially disarranged 
than the lower, though the latter frequently exhibit 
some irregularity, in consequence of a crowded con- 
dition. The teeth most liable to be out of position 
are the cuspidate. These, of the permanent teeth, 
are the last in their eruption ; and it often occurs that 
the arch is previously well-nigh occupied, in which 
case they are thrown outward. When there is any 
irregularity of the bicuspids, it is usually that of 
an inward inclination, though they are sometimes 
turned upon their axes. The first and second molars 
are very seldom out of proper position. The third 
molars, for want of room, are sometimes thrown out 
toward the cheek, or tip forward, and come in con- 
tact with the posterior side of the second molar, 



30 INTRODUCTION. 

and farther growth is not possible, or they may be 
prevented from coming out at all in any direction. 

Effects. — In all cases, irregularity is favorable to 
decay. It is even maintained hy some that the organic 
structure of irregular teeth is less perfect than that 
of regular, because the former are impeded in their 
eruption, and thus impaired. But this, to say the 
least, is questionable ; for it will be remembered that 
the crowns of the teeth are formed and ossified before 
they can be much affected by a crowded state ; and 
it is hardly probable that they could be materially 
modified in their structure after this period. The 
crowns of the teeth are rarely if ever deformed by a 
crowded condition. The principal reason of the lia- 
bility of irregular teeth to decay, is the facility they 
furnish for the lodgment of foreign substances about 
them, and the difficulty they present to its removal. 
And, again, in irregular teeth, parts are approximated 
that nature did not intend should be brought together. 
Irregularity impairs the speech, impedes mastication, 
and often distorts the countenance and deforms the 
features. 

Atrophy. 

This affection is characterized by defective spots in 
the enamel, — white, chalk-like, — which scarcely ever 
penetrate the dentine. In these spots there is little 
or nothing of that organic structure exhibited by 



ATEOPHY. 31 

well-formed enamel. They are usually small, but 
vary greatly in number. They are often found ar- 
ranged in transverse rows across the tooth affected. 
The superior incisors are most frequently affected 
with atrophy, though the bicuspids and molars some- 
times exhibit it. The front upper teeth are attacked 
by it only on the anterior surfaces. 

Instead of the spots, sometimes pits or indenta- 
tions into or through the enamel are found, which 
occasionally run together, so as ultimately to form 
transverse grooves of considerable extent upon the 
teeth. In many cases, where on the eruption of the 
teeth the spots only are presented, the organs are not 
injured, except in appearance, the spots retaining 
the smooth, enamel-like surface during life. In other 
cases, the spot is of such a soft, friable texture, that 
it early crumbles out, leaving the pits above referred 
to. These indentations, however, sometimes exist at 
the first appearance of the tooth, but more frequently 
afterward, being formed by the disintegration of the 
defective portion. Atrophy is sometimes shown in 
the shrivelled, and more or less corrugated condition 
of the enamel upon the ends of the teeth. 

Atrophy usually occurs on teeth of good structure, 
short, thick crowns, and rather yellowish color. The 
long, thin, white tooth, of imperfect organization and 
insufficient density, but seldom, if ever, presents an 
atrophied condition. 



32 INTRODUCTION. 

The Cause. — It may be difficult to point out the 
precise cause of this affection, but some facts in re- 
gard to it are very obvious. There is in every case 
an obstruction in the development of the enamel at 
the point of defect, and at the time of its organiza- 
tion. In some cases, doubtless, there is a deficient 
amount and an inferior quality of the materials elab- 
orated for the upbuilding of the structure; and this 
is probably the case when the pits exist at the erup- 
tion of the teeth. In other cases, the requisite quan- 
tity of materials may be elaborated, and yet the vital 
energy be insufficient to organize it, as in the case 
of the spots referred to. The latter condition is more 
frequent than the former, as is evidenced by the 
more frequent appearance of the spots than of the 
pits. We are led to infer, then, that the origin of 
this affection is, for the most part, constitutional, 
and not local. There are commonly found traces of 
it on all the teeth whose enamel was in process of 
formation at the time of the interruption. 

Any general disturbance, such as to interrupt the 
assimilative process, would be detrimental to the per- 
fect formation of the tooth. Again, some affections 
may materially affect the organizing ability of the sys- 
tem without interfering with the assimilative power. 
Any disease that interrupts the functions of the di- 
gestive apparatus is prejudicial to the process of as- 
similation; whilst other diseases, such, for instance, 



EXOSTOSIS. 33 

as those of a febrile character, would diminish the 
vital power, and consequently the ability to build up 
organic structures without interrupting in any special 
manner the process of assimilation. These things 
are referred to here for the purpose of showing under 
what circumstances atrophy of the teeth may occur. 
Effects. — In the best formed teeth there are no un- 
pleasant results from atrophy other than its detrac- 
tion from their beauty, and sometimes being the oc- 
casion of decay. The spots are unsightly, and when 
the pits are present they become dark, and sometimes 
black, from deposit, which, by ordinary means, is 
difficult of removal. In teeth of inferior structure 
decay often supervenes in these pits, and, extending 
thence, involves the other parts ; and anything that 
will affect the tooth-substance will find a beginning 
place in these spots. 

Exostosis. 

This term, critically defined, implies outgrowth from 
a bone ; but, as applied to the bones generally, and 
particularly to the teeth, it probably conveys the 
idea of growth upon the bone. The affection thus de- 
nominated is common to all the bones ; some, how- 
ever, being more frequently attacked by it than 
others. It occurs upon the roots of the teeth, but is 
never developed where there is no periosteum. It is 
so nearly allied in structure and character to the ce- 

3 



34 INTRODUCTION. 

mentum that covers the roots of the teeth that it may 
he regarded as hypertrophy of that tissue. The 
manner of its accumulation is not uniform, but it 
commonly consists of an enlargement on the point 
of the root, or from the point some distance toward 
and occasionally all the w&y to, the neck of the tooth. 
In some cases it extends entirely round the root, and 
in others is confined to one side. It sometimes re- 
sults in such an enlargement of the root, especially 
if it is near the point, as to render the tooth very 
difficult of removal. When the root is bulb-form, its 
attachments may be broken up, so as to allow it to 
rotate in the socket, and yet be very difficult to re- 
move ; indeed, in some instances impossible, without 
cutting away a portion of the process. 

The density of the deposit does not vary much 
from the primary cementum of the root on which it 
is found, though in this respect there is sometimes 
slight variation ; in a few instances we have found 
it softer than the normal cementum. The tooth 
socket is enlarged, chiefly by absorption for its ac- 
commodation. The color of the substance is slightly 
yellow, not differing much from that of the root 
itself; but sometimes it exhibits a semi-translu- 
cent appearance. The rate of its formation varies 
considerably, sometimes increasing so rapidly as to 
occasion difficulty, by impingement upon the sur- 
rounding structure, especially upon nerve branches, 



EXOSTOSIS. 35 

and at other times seeming to advance very slowly; 
and frequently it is arrested altogether. Roots are 
often found affected with exostosis that have been 
dead and crownless for a number of years, and yet 
have never, so far as known, given any trouble 
because of the affection. Teeth perfectly healthy in 
other respects may be thus affected. 

Its Effects. — It usually increases the difficulty of 
removing the tooth, either by enlargement of the 
point of the root or by deposit upon one side of it, 
causing it to curve ; in which latter case the difficulty 
is all the greater, from the impossibility of deter- 
mining the direction of the curve. It sometimes 
produces a diseased condition of the surrounding 
parts — in some instances chronic inflammation — that 
may continue as long as the tooth remains. Nervous 
affections often result from exostosis, either through 
irritation, caused by pressure on the pulp, or through 
the diseased condition of the surrounding parts. The 
floor of the antrum is sometimes absorbed away, in 
consequence of the enlargement of the point of the 
root ; and then disease of the lining membrane of 
that cavity may occur. 

The Cause. — The cause of this affection is not well 
understood; though much light has been thrown 
upon it by the researches upon the reproduction of 
bone, and especially so far as the function of the 
periosteum is concerned. It is most probably de- 



36 INTRODUCTION. 

posited by the periosteum when this is in a state 
of irritation; but what particular condition, is not 
clearly ascertained, though some have supposed it to 
be inflammation. It is manifest, however, that some- 
thing different from a state of simple inflammation 
exists ; for there is inflammation in numerous in- 
stances without this deposit. Again, in all cases 
where there is periostitis, that state is definitely indi- 
cated by percussion upon the affected tooth; indeed, 
in the occlusion of (he jaws, pain is usually experi- 
enced. Yet there are found many teeth whose roots 
are subjects of this deposit, that have never given 
any indications, either by pain or otherwise, of a dis- 
eased condition. 

This subject is one in which there is room, at least 
so far as dentists are concerned, for more definite 
observation. 

Denuding. 

This consists in a wasting away of the enamel of 
the anterior teeth, from the points toward the necks. 
The affection, however, is of too rare occurrence to 
demand extended consideration. The color of the 
enamel is not changed by this process, nor is its 
natural polish impaired by abrasion. The dentine, 
on becoming exposed by this removal of its natural 
protection or covering, is perfectly smooth, but of a 
yellowish cast, in some cases inclining to brown. 



DENUDING. 37 

When the enamel is removed, there seems to be a 
cessation of the destructive process ; for the crowns 
of such teeth will, in many instances, endure for a 
long time — indeed, till they are worn down by the 
friction in mastication. 

This wasting process usually begins at the points 
of the teeth, and proceeds toward the necks, on all 
sides, till the enamel is entirely destroyed. Some- 
times, however, it commences on their labial surfaces; 
this is particularly the case with the superior an- 
terior, but very seldom with the inferior teeth. The 
affection, however, attacks the inferior more fre- 
quently than the superior teeth; yet it is found 
assailing both with about equal energy. 

The cause of this affection is not well understood, 
though it is generally conceded to be by the opera- 
tion of an acid contained in the mucus ; and this, 
with but little doubt, is the source of the agent ; for 
the destructive process usually occurs where there 
is a large relative amount of this secretion ; but that 
it is an agent of a very decided acid character, we are 
not prepared to affirm. Decay of the teeth does not 
seem to progress with greater rapidity while this 
affection exists than at other times ; and again, the 
enamel does not present the roughened, abraded ap- 
pearance resulting from the operation of any ordinary 
agent. With these apparently incongruous facts, it 
is rather difficult to arrive at a definite conclusion as 



38 INTRODUCTION. 

to the precise manner in which this condition is pro- 
duced, or the exact character of the agent instru- 
mental in its production. 

Chemical Abrasion. 

This consists in a gradual destruction of the entire 
substance of the crown of the tooth — the enamel and 
the dentine. It is an affection of comparatively rare 
occurrence. It attacks the superior more often than 
the inferior teeth, though both are subject to it. It 
begins upon the points of the central incisors, wasting, 
them away more rapidly at the median line, from 
which it progresses each way, involving the lateral 
incisors, cuspids, and sometimes the bicuspids, so that 
a curved line is presented by the edges of the teeth, 
of greater or less inclination, according to the rapidity 
of the process. When the superior teeth only are 
affected, the opening between the ends of the upper 
and of the lower front teeth, when closed, is a semi- 
ellipsis. If the inferior teeth are affected, as is some- 
times the case, then the opening will be an ellipsis. 

In the case of Mr. G., the affection had been pro- 
gressing about two years and a half; the wasting away 
extended to the first bicuspids both above and below; 
and when the jaws were closed, the ends of the upper 
and of the lower central teeth, were about one-third 
of an inch asunder, and the opening was of the ellip- 



CHEMICAL ABRASIOX. 39 

tical form. It was a mystery to him. Two years 
and a half before, his anterior teeth shut close to- 
gether on the ends. He had not used them in the 
mastication of his food, for his molar teeth were all 
good, and sufficient for this purpose ; and, moreover, 
it had been impossible for him to use them in masti- 
cation, since he could not bring them together ; and 
he had not been in the habit of using them upon any 
hard substance. 

The Cause. — The cause of this affection, like that 
of denuding, is not well understood. It is supposed, 
however, to be induced by an acid contained in the 
mucus. If this supposition is correct, it must be 
some acid with whose nature we are but little, if at 
all, acquainted ; or, if any ordinary acid, it certainly 
must be modified by very peculiar circumstances, so 
that it effects a solution of both the animal and the 
earthy constituents. The surface upon which it acts 
is always perfectly smooth and polished, never pre- 
senting that roughened and abraded appearance 
caused by the action of any ordinary acid upon en- 
amel or dentine. And again, if this affection results 
from the operation of an acid in the mucus, why does 
not this acid, to some extent at least, affect the teeth 
at other points? Such is not the fact; and caries 
that has previously commenced at other points on the 
teeth, does not progress more rapidly during the ex- 
istence of this disease than before ; but it certainly 



40 INTRODUCTION. 

would if there were a large quantity of acid in the 
mucus. 

It has been supposed that the mucous follicles of 
that part of the tongue which comes in contact with 
the teeth at the affected part, are the agents that 
produce the disease. Of this, however, there is not 
evidence sufficient to warrant an adoption of the 
theory. The cupping of the molars and bicuspids 
bears strong indications of being an analogous pro- 
cess, and yet no such influence can there operate for 
its accomplishment. We have no theory on this sub- 
ject to present, regarding it as still an open field for 
investigation. There can be little doubt, however, 
that the cause of denuding, of chemical abrasion, and 
of cupping, has its origin in the constitution, is not 
merely local, and its arrest must be effected, chiefly 
by constitutional treatment. 

Necrosis of the Teeth. 

By this term is understood the death of the part 
involved. It has been remarked that the condition 
is similar to mortification in the soft parts. But in 
I the latter there occurs a change of structure, whereas 
in the. bones, and particularly in the teeth, there is 
not necessarily any immediate structural change con- 
sequent on the loss of vitality. The teeth have their 
organic connection with the surrounding parts by the 



NECROSIS OF THE TEETH. 41 

external and the internal periosteum and the pulp ; 
their crowns depend chiefly for vitality upon the in- 
ternal organism, as is evident from the total loss of 
sensibility in them immediately after the destruction 
of the pulp. 

Necrosis of the teeth diners from that of the other 
bones in some particulars, one of the most obvious 
of which is, that in the former there is no exfo- 
liation, the living structure not having the power 
to throw off the dead or necrosed portion. Again, 
a dead part in contact with the living does not ma- 
terially affect it. The roots of the teeth depending 
for their vitality upon both their internal and their 
external connections, the former of these connections 
may be destroyed without materially affecting the 
latter. Thus, a tooth may be partially necrosed, — 
that is, vital in one part and dead in another, — 
without immediate injury to the living portion, and 
without separation of the living from the dead. It 
is a happy provision that the analogy between the 
teeth and the other bones does not, in this respect, 
obtain, for if it did, we should find the crowns of the 
teeth separated from the roots in all cases immedi- 
ately after the death of the pulp. 

There results but little change of color to the teeth 
from necrosis, unless coloring matter is absorbed by 
the dentine from the decomposed pulp; though, of 
course, the life-like lustre and appearance of the liv- 



42 INTRODUCTION. 

ing teeth are not present. Total necrosis destroys 
the entire organic connection of the teeth with the 
surrounding parts, in which case they are very soon 
expelled from their sockets as useless. 

Causes. — Caries is a very common cause of ne- 
crosis, especially the partial form of it to which ref- 
erence is made above. Protracted fever, or diseases 
of any kind that diminish the vitality of the system, 
will, in a corresponding degree, diminish that of the 
teeth, and sometimes destroy it entirely. Excessive 
medication, especially with mercurials, will some- 
times produce partial, and occasionally total, necro- 
sis, as will also blows or violent shocks, even when 
these are not sufficient to displace the teeth. Sudden 
and extreme thermal changes have been reckoned 
causes of this affection, but it may well be doubted 
whether they are adequate without the concurrence 
of other influences. 



CHAPTER II. 

CARIES OF THE TEETH. 

Notwithstanding the teeth are so important in the 
human economy, having functions so various and so 
extensive to perform, they are greatly neglected in 
most instances, and in many subjected to positive 
violence, as, for example, in crushing or biting hard 
substances, sustaining weights and suffering severe 
blows, sudden extremes of temperature, bungling 
dental operations, etc. Very few give that attention 
to these organs which is requisite to preserve them 
from injurious influences- and owing to artificial 
modes of life, and consequent impairment of health, 
this is often difficult to do. Indeed, these influences 
are frequently not known, and the causes of disease 
in the teeth not explored. 

Such is the truth, to some extent, in regard to 
caries, though this affection is more generally a re- 
sult of conditions well understood. The dentine is 
affected more frequently by caries than by any other 
form of disease. It is both frequent in occurrence 
and fatal in tendency. Scarcely any that have at- 
tained maturity are exempt from its ravages. It is 
a disease which the vital forces, owing to the nature 



44 CARIES OF THE TEETH. 

of the tissue, can but feebly withstand, at least with 
far less efficiency than in more highly organized struc- 
tures, and the restorative process is wholly inopera- 
tive here. Some maintain that softened dentine does, 
in many cases, regain its normal density; but this 
can hardly be, unless it retains some degree of vi- 
tality, except possibly by infiltration. But any agent 
possessed of sufficient energy to decompose the den- 
tine will destroy its vitality ; yet, a partial removal of 
lime salts is not always incompatible with, or destruc- 
tive to vitality; in such cases the normal density of the 
affected part may be fully restored, and even increased 
growth has, in a few instances, been observed. In 
decay, there is a lack of vital power to maintain the 
integrity of the organic structure, or there is the ac- 
tion of some agent having an affinity for a certain 
part of the dentine more potent than that vital 
power. In either case the vitality is destroyed. In 
an organized structure the entire removal of one of 
its essential constituents occasions a loss of vitality. 

Caries usually makes its first attack upon the 
dentine, and progresses most rapidly in the direc- 
tion of the tubuli. There are variations from this 
course; as, for example, in the large superficial caries 
on the labial surfaces of the superior incisors. In 
many cases, too, it extends immediately beneath the 
enamel. Portions of the dentine imperfectly pro- 
tected by the enamel, on account either of an injured 



CARIES OF THE TEETH. 45 

condition or of an imperfect formation of the latter, 
are liable to be attacked by this disease ; and points 
that, by their location or any other unfavorable cir- 
cumstance, retain injurious agents in contact with 
the tooth, are very subject to decay. 

The attack and progress of caries are modified by 
the constitution of the teeth. These may be defec- 
tive, either originally or accidentally. Original de- 
fectiveness extends to all the teeth of the same 
individual, whilst accidental exists only as to some 
of the teeth in the same mouth, and these only at 
particular points. Such conditions are peculiarly 
favorable for the attack of caries. When the whole 
crown of the tooth is imperfectly organized, the decay 
will progress with uniform rapidity, under the influ- 
ence of uniformly persistent agents, till the whole is 
destroyed. But when it is only a portion of the 
tooth, the caries after a time becomes retarded in its 
progress, and in some cases checked altogether. 

Among the circumstances which modify the prog- 
ress of this disease, are, a change of the condition or 
character of the agencies producing it, and an in- 
crease or diminution of the amount of such agencies. 
The progress of caries will also be governed somewhat 
by the age of the person whose teeth it attacks, as 
well as by the peculiar constitution of the organs 
themselves; for, in regard to constitution, they pre- 
sent an almost infinite variety, 'the relative propor- 



46 CARIES OF THE TEETH. 

tions of their constituents being exceedingly various, 
even in persons of the same age, and continually 
varying in the same person at different ages. There 
is a constant change going on, the calcareous elements 
usually increasing, and the animal decreasing. But 
a proper relative amount of elements may be elab- 
orated, and yet a defective organization exist. This 
condition arises from defective organizing power, or 
from a failure in arrangement and combination of 
the materials, and is dependent entirely on accidental 
causes. In vital energy, indeed, the teeth exhibit 
great diversity; and this corresponds with, and to 
some extent depends upon, the vital energy of the 
general constitution. Dead dentine is decomposed 
more readily than living ; and hence the conclusion 
that vitality resists caries, and that this resistance 
corresponds with the vigor of the vitality. 

The points most frequently attacked by caries are 
the proximate surfaces of the teeth, the indentations 
and fissures on the masticating surfaces of the molars 
and bicuspids, the longitudinal depressions on the 
buccal and palatal walls of the molars, and the necks 
of the teeth at the termination of the enamel. On 
the proximate surfaces, the enamel is thinner than 
elsewhere; and the situation is peculiarly favorable 
for the accumulation and retention of injurious 
agents. The union of the enamel in the fissures and 
indentations of the crowns of the molars is often im- 



CARIES OF THE TEETH. 47 

perfect; and thus there is a way of entrance for 
vitiated fluids to the dentine. Decay is found at the 
termination or intersections of these fissures earlier 
than at any intermediate points. The indentations, 
or grooves, on the sides of the teeth are usually at- 
tacked by caries at that point next to the neck. Less 
frequently, the disorder is exhibited at the neck, just 
beneath the border of the enamel, under which it 
burrows with a transverse extension. 

The order in which the elements are removed is 
governed by the nature of the agent which effects 
the decomposition ; and this is usually one having 
an affinity for the calcareous elements strong enough 
to destroy the texture of the dentine, and remove 
the earthy portion. Those acids which have an 
affinity for the lime of the dentine, produce its de- 
composition in this manner. When the decay is 
thus caused, the portion remaining in the cavity is 
soft, and approximates the gelatinous condition as 
the calcareous material is abstracted. Agents of a 
different character, too, often produce decay. Alka- 
lies will act upon the animal portion of the dentine, 
and remove it; and in caries thus produced, the 
residue is friable and chalk-like. 

In other cases the constituents are simultaneously 
removed. Nitric acid will cause an entire break ing- 
up of both the earthy and the animal constituents. 

The dentine outside of the decay may be in an 



48 CARIES OF THE TEETH. 

inflamed and irritable condition, so that the contact 
of an instrument with the decayed portion will pro- 
duce pain ; and thus we may be led falsely to con- 
clude that the softened dentine is sensitive, and, 
indeed, it is maintained that in some cases the par- 
tially decomposed dentine is so, on the supposition 
that a small portion of the calcareous elements may 
be removed and yet the vitality of the part not be 
destroyed. 

The progress of caries is far more rapid in the 
crowns of the teeth than in the roots, for the reason 
that the former are more exposed to the influences 
of external injuries. It is true that the crowns are 
covered by enamel, which is designed to shield the 
dentine from injury, but this is often defective, and 
on it are accumulated agents that it cannot resist 
even when it is perfect, so that the enamel itself is 
sometimes decomposed. The roots receive nourish- 
ment from without as well as from within, and be- 
cause of this possess a higher degree of vitality than 
the crowns, and their ability to resist the encroach- 
ments of decay is correspondingly greater, and hence 
we often find the roots of teeth solid and free from 
decay the crowns of which have been removed by 
rapid decomposition. Injurious substances are some- 
times pressed into contact with the dentine through 
defects in the enamel, or under its projections, and 



CARIES OF THE TEETH. 49 

there retained till their mischievous effect is pro- 
duced. 

It is maintained by some writers that caries is con- 
tagious. Dr. Koecker was of this opinion. The 
question, then, is, whether there is any property in 
the decayed dentine of one tooth capable of produc- 
ing the same condition in the healthy dentine of an- 
other? The residue of dental decay consists of the 
organic or animal constituents and a small portion of 
earthy material, and in decay, in which the gelati- 
nous constituent is abstracted, the remainder is chalk- 
like, consisting mainly of phosphate of lime. In 
neither of these is there anything that can possibly 
operate on the healthy dentine. There is one thing 
here, however, that is worthy of remark, and that has 
perhaps led to the mistaken notion that caries is 
contagious : decayed dentine will absorb and retain 
fluids that injuriously affect sound dentine, and when 
the decay is on the proximate portion two teeth are 
subject to the same exciting cause. But it is seldom 
that two teeth thus situated are both in the same 
stage of decay — a fact principally attributable to the 
difference in their constitution or susceptibility. The 
decay of the teeth in pairs has also been adduced as 
evidence of the contagious character of the disease. 
This, however, results from the fact that the pairs 
are formed at the same time, are subject to the same 
influences in their formation, and hence are consti- 

4 



50 CAEIES OF THE TEETH. 

tuted alike, and if one of the pair is defective, the 
other will probably be in a like condition. When 
there is a vitiation of the saliva or mucus they will 
be similarly affected. In no common acceptation of 
the term contagious can it be applied to caries of the 
teeth. 

The color of caries is exceedingly various, from 
that of healthy dentine, through every intermediate 
shade, to jet black. The rate of the progress is in- 
dicated by the color of the decay, being slower as it is 
darker, so that when the decay becomes almost sta- 
tionary, the affected portion is usually black. The 
degrees of color are differently enumerated by different 
writers, as, by Koecker, five, by others, seven, and 
so on. Three, however, are sufficient for our purpose : 
white, brown, and black. The sensitiveness of the 
dentine is greatest in teeth affected by the white de- 
cay, and usually decreases as the color darkens ; 
though there are exceptions to this rule, for occa- 
sionally the teeth affected by dark decay are quite 
sensitive. The light-colored decay is more difficult 
to arrest than the dark. In many cases of the former 
filling seems hardly to retard its progress; whereas, 
in the latter, by proper filling, the advance of the 
decay may be checked altogether. The cause of the 
dark color of caries is mainly due to the carboniza- 
tion of the animal portion. 

The dark, and especially the black variety of decay 



CARIES OF THE TEETH. 51 

is much less rapid in its progress than the light, brown 
or white variety, and chiefly because the debris or re- 
siduum is insoluble, and much less disintegrated than 
in the other varieties, the animal part being retained 
in a carbonized state, and the calcareous constituent 
to a considerable extent retained, and in a form not 
soluble in the fluids of the mouth. 

Thus a far better protection to the dentine beneath 
is present in the black than in any other variety of 
decay. 

Some sensitiveness commonly accompanies caries. 
It does not often amount to pain, but is rather a 
sense of uneasiness ; yet, from change of tempera- 
ture, or contact of acids or hard substances, intense 
pain may be produced. Dr. Koecker remarks that 
caries is most tender in its first stages; and Dr. 
Cone that when a tooth is attacked by it the sensi- 
tiveness is increased. The surface of the dentine is 
susceptible of the most acute sensitiveness. When 
there is inflammation of the dentine, intense pain 
may be produced by the contact of an instrument 
in a cavity of decay, at the line of union of the den- 
tine with the enamel, with very little sensitiveness 
present elsewhere in the cavity. Sensitiveness of a 
uniform character sometimes pervades all parts of 
the cavity, while at other times it may be very in- 
tense at one point, and very slight or entirely absent 
at any other. A thin lamina of the dentine lining 



52 CARIES OF THE TEETH. 

the whole cavity may be uniformly sensitive, and in 
some cases sensitiveness involves the entire body of 
the dentine. 

By means of this sensitiveness, warning is trans- 
mitted to the pulp, which emits calcareous material 
with increased energy ; and thus a process of filling 
up the natural cavity of the tooth is instituted, that 
the decay may not encroach upon the pulp. But this 
warning may in some degree be transmitted to the 
pulp though there be no appreciable increase of sen- 
sitiveness. 

This sensitiveness is modified by the character of 
the teeth, the nature of the decay, and the state of 
the patient's system. The teeth of the same person 
will be more sensitive at one time than at another, 
because of a greater irritability of the nervous system. 
Those teeth which decay most rapidly are usually 
most sensitive ; though in teeth whose vitality is lost 
considerably in advance of their decay, there is no 
perceptible sensitiveness present. Except in such 
cases as last mentioned, the whitest and most rapid 
decay has most sensitiveness, the brown much less, 
and the black scarcely any. 

Predisposing Causes of Caries. 

The causes of caries of the teeth may be considered, 
under two general divisions — predisposing and excit- 



PREDISPOSING CAUSES OF CARIES. 53 

ing. Of the former some are original, others acci- 
dental. The original development of the constitution 
may be defective, either from original or from acci- 
dental defect in the parent, but more certainly from 
the former. Constitutional characteristics are trans- 
missible, and a defect is as surely hereditary as any- 
thing else. In the foetus, during gestation, germs 
may have originated from which perfect organs can 
never be developed, and these germs may be more or 
less defective according to the constitutional condition 
of the mother, or according to accidental conditions to 
which she may be subject, and which may seriously 
affect the foetus. After birth, too, the child is exposed 
to injurious impressions, which will, to a greater or 
less degree, render the development defective ; as 
imperfect nourishment and the diseases and func- 
tional derangements peculiar to childhood. A dis- 
eased condition, or functional derangement, will 
interrupt the proper elimination and perfect upbuild- 
ing of the materials necessary for the perfect struc- 
ture ; and indeed anything that will disturb the 
equilibrium of action in the system may be detri- 
mental to the teeth. 

In some instances the teeth will exhibit the pecu- 
liarities of the mother, and in others those of the 
father, while sometimes they simulate those of both 
parents ; and when the parental imprint is thus found 
stamped on the teeth, it will also be found that those 



54 CARIES OF THE TEETH. 

of the same class decay at the same points and at 
about the same age as in the parent. In such cases 
the defect is manifestly hereditary; it cannot be ac- 
cidental : the coincidences thus constantly occurring 
preclude any other conclusion. Hereditary taint, 
then, may be regarded as a predisposing cause of 
caries. 

Impaired vitality is another predisposing cause ; 
and not only impaired vitality of the teeth and con- 
tiguous parts, but also that of the general system. 
Indeed, the vital vigor of the teeth depends upon 
that of the general system, and, when there is no 
local adverse influence at work, corresponds with it; 
so that when the general system is in the most 
healthy condition, the teeth possess the greatest 
power of resistance to deleterious agencies. This re- 
sisting power is, at best, comparatively feeble; but 
its feebleness is to some extent compensated by the 
peculiar structure of the teeth, which are less liable 
to decomposition than any other part of the human 
body. Yet the integrity of these organs depends 
much on the maintenance of a healthy vitality, and 
this on that of the general system. A dead tooth 
will decay far more rapidly than a living one in simi- 
lar circumstances ; and hence the conclusion that 
vitality resists injurious agents, and that the resist- 
ance will be in proportion to the vigor of the vitality. 

All febrile conditions promote and facilitate decay, 



PREDISPOSING CAUSES OF CARIES. 55 

and frequently in two ways : by diminishing vitality, 
and by changing the secretions of the mouth so that 
these act, either directly or indirectly, injuriously 
upon the teeth. Accompanying such conditions there 
is generally inflammation of the dentine ; and in such 
cases this always partakes of the general disorder, so 
as to become very susceptible to injury. All diseases, 
indeed, that impair the vitality and change the secre- 
tions, may be considered predisposing causes of decay, 
and some even more ; dyspepsia, for instance, being 
not only predisposing, but also exciting, since it pre- 
pares in the stomach an acid that is almost contin- 
ually thrown upon the teeth, and that acts upon them 
with great energy. Eesidence in miasmatic regions is 
also a predisposing cause, inducing unfavorable con- 
ditions. 

Diminished vitality may result either from systemic 
or from local causes. These latter are such as pro- 
duce an irritable or diseased condition of the con- 
tiguous parts, or an abnormal condition of the den- 
tine, without the power to effect its decomposition. 
Local causes of a diminution of vitality are not in 
their character so formidable, and not so difficult to 
control, as those which are constitutional. 

Many medical agents are regarded as predisposing 
causes of caries, and among these mercurials occupy 
a prominent place. They operate by vitiating the 
secretions of the mouth, and producing an abnormal 



56 CAKIES OF THE TEETH. 

condition of the periosteum about the roots of teeth, 
the mucous follicles and the salivary glands. Some 
entertain the opinion that the abnormal action of 
the absorbents induced by mercurials predisposes to 
decay. 

Dental operations performed at an improper time, 
and in an improper manner, may be reckoned among 
the predisposing causes of caries. The vitality of 
the teeth may be thus impaired, or a diseased condi- 
tion established, or the part operated upon may be 
permitted to remain rough, so that foreign substances 
will be retained, and, becoming vitiated, produce a 
deleterious effect. Often, from an improper use of 
the file, extensive inflammation of the dentine super- 
venes, which is sometimes followed by death of the 
tooth, and by disease of the contiguous parts. Arti- 
ficial substitutes, imperfectly adapted, are in many 
instances the occasion of caries; not that clasps or 
the edges of the plate tend directly to injure the 
teeth, but the agencies superinduced by them do, 
and especially when the material used is not of the 
right quality. 

Lack of proper exercise in mastication induces a 
condition favorable to decay, both by favoring the 
action of injurious agents upon the teeth, and by with- 
holding the stimulus of normal exercise. Calculus 
and other deleterious substances are much more 
rapidly deposited when the teeth are idle. 



EXCITING CAUSES OF CARIES. 57 

The teeth cannot with impunity undergo great 
and sudden transitions of temperature, or even such 
variations as may be endured by the surrounding 
parts. By these, inflammation of the dentine may 
be induced, and the vitality of the teeth dimin- 
ished. And in friable teeth, checking of the enamel 
maj r occur, and thus a condition arise that will pro- 
mote decay. 

Exciting Causes of Caries. 

When there is a predisposition to caries, any of 
the exciting causes act with more effect. Well-organ- 
ized teeth, of unimpaired health and vitality, with- 
stand influences that in less favorable circumstances 
destroy them in a very short time. The immediate 
cause of decay is the action of agents chemically 
upon the teeth. It is not here proposed to enter 
upon an investigation of the manner in which these 
various agents operate, for that would open up a 
large field for consideration — a field outside of the 
province of this work. The sources of these, how- 
ever, are several : as, vitiated secretions of the mouth; 
the saliva and the mucus; abnormal secretion from 
the stomach ; decomposition of animal and vegetable 
substances in the mouth, etc. 

The natural state of the mucus is acid, but that 
of the saliva alkaline, and under proper balance 
the mixed fluid is neutral ; but when the saliva and 



58 CARIES OF THE TEETH. 

the mucus are both acid, the teeth must suffer. These 
secretions may become vitiated through inability of 
the glands, from disease or an enfeebled condition, 
perfectly to perform their functions ; or the blood 
may be in an abnormal state, and the glands unable, 
on that account, though they were healthy, — as they 
seldom are in such case, — to elaborate healthy saliva. 
When the fountain is corrupt the stream cannot be 
pure. Thus some things, at least, that produce a dis- 
eased condition of the blood tend to the decay of the 
teeth ; and such diseased condition often has a di- 
rectly injurious effect on the secretive apparatus, and 
so works a double harm. 

But to the theory of the pernicious influence of 
the saliva it may be objected, that, if it were true, all 
parts of the teeth would be alike affected. This ob- 
jection, however, will lose its force when it is con- 
sidered that the teeth, in many cases, are not equally 
well-organized in all their parts, some much more 
vulnerable than others; that some parts are not so 
well protected as others; and that between the 
teeth there is room for the retention of saliva and 
foreign substances, which there combine their influ- 
ence upon them. When there is a great quantity of 
viscid saliva constantly flowing, the teeth decay very 
rapidly. The decay is of a light color, so light, in- 
deed, that in many instances it is difficult to dis- 
tinguish it, by this, from undecomposed dentine. 



EXCITING- CAUSES OF CARIES. 59 

The gastric fluid often becomes deranged by irri- 
tation or disease of the stomach, so that the function 
of the latter is very imperfectly performed, and fer- 
mentation of the food occurs, evolving agents that 
injuriously affect the teeth. In dyspepsia, such 
agents are often brought in contact with the teeth 
by eructation and vomiting, and the diseased gastric 
fluid, which contains hydrochloric acid, is also thus 
brought in contact with them, acting with great 
energy. After food commingled with this secretion 
is ejected from the stomach, the teeth will be found 
corroded over all their surfaces. Dyspeptics will ap- 
preciate this remark. In such cases, if the teeth are 
not of superior organization, they are destroyed in a 
short time. Their surfaces, thus roughened, afford a 
lodgment for foreign substances on all parts. 

The most common agents, however, that injure the 
teeth, are originated in the mouth by the decompo- 
sition of animal and vegetable matter. By this 
process, elements are eliminated that form new com- 
binations, and these operate with energy in the 
destruction of the teeth. Favorable conditions exist 
in the mouth for such decomposition, and also for 
such new combinations ; for there is a sufficient 
amount of heat and moisture, — for both of these, 
especially the former, facilitate the action of any acid 
upon the dentine. The character of the saliva and 
mucus will very much modify the decomposition of 



60 CARIES OF THE TEETH. 

foreign substances in the mouth. If these secretions 
are both acid, the decomposition will be much more 
rapid, and more potent in its effect. 

Again, it is sometimes the case that the salivary 
glands are comparatively inactive, except when spe- 
cially excited, and yet the mucous glands still effi- 
cient, eliminating their secretion ; so that the mouth 
assumes an acid condition, because there is not saliva 
sufficient to neutralize the mucus, in which condition 
decomposition of foreign substances would be greatly 
accelerated. There are many cases, however, in 
which the flow of saliva is copious, and yet the decay 
rapid, which is in consequence of an acid condition 
of both secretions, or of a speedy decomposition of 
foreign substances in the mouth. 

There are acids taken with the food that act 
directly upon the teeth ; as acetic acid, or vinegar. 
It has generally been supposed that acids taken with 
the food act directly upon the teeth. 

Professor Westcot says : " Acetic and citric acids 
so corroded the enamel in forty-eight hours, that 
much of it was easily removed with the finger nail, 
and malic acid or the acid of apples, in its concen- 
trated state, also acts promptly upon the teeth.' , 
These acids, in the use of many kinds of food, are 
brought into frequent contact with the teeth. 

But these and similar acids, however freely they 
may be used, exercise no direct influence in the pro- 



EXCITING CAUSES OF CARIES. 61 

duction of the common dental decay. But these and 
such acids do play an important part indirectly in 
the erosion and roughening which they produce upon 
the surfaces of the teeth, with which they are brought 
fully in contact, thus making vulnerable points of 
attack for the acting agents of decay. 

Another way in which these common acids act 
indirectly is by promoting the decomposition of sub- 
stances from which arise the agents that do effect 
decay of the teeth. 

In the manufacture of vinegar, sulphuric acid is 
often employed ; so that in this article of food we 
have that acid either alone or combined with the 
acetic, the former acting with greater energy upon 
the teeth than the latter. Acetic acid also facilitates 
the fermentation of food retained in the mouth, and 
thus reproduces itself in abundance. 

After eating apples that contain a large amount of 
malic acid, the teeth will be found corroded over all 
their surfaces. This acid, as well as the others, 
affects the enamel somewhat, and when the latter is 
very thin, though it may not be all removed from 
any particular point, yet its integrity will be de- 
stroyed, so as to be readily fractured, thus admitting 
injurious agents to contact with the dentine, which 
is much more susceptible of injury from acids than 
the enamel : points imperfectly protected by this are 
violently attacked by acetic, malic, and sulphuric 



62 CARIES OF THE TEETH. 

acids, especially when in the nascent state. In 
decayed cavities these agents produce rapid results. 
They should be as much as possible avoided, and, 
when necessarily used, should be removed from the 
teeth by cleaning with great care. It would be safest 
to employ some neutralizing agent after the use of 
any acids with food. During mastication, there is an 
increased secretion of saliva, which, if in a healthy 
state, will tend to neutralize any acid that may at 
the time be present, and also, by its flow, to remove 
foreign substances from the mouth. 

Some acids combined with metallic or alkaline 
bases, are used as medicines, some of them are easily 
decomposed, when the newly liberated acid will act 
with energy upon the teeth ; but even this does not 
produce the ordinary decay, acting only upon the 
surfaces of the teeth, whenever it may come in con- 
tact with them. 

Many medical preparations contain agents pecu- 
liarly deleterious to the teeth, acids being especially 
in requisition for these, and oftentimes in considera- 
ble quantities. The acids most commonly thus ad- 
ministered are the hydrochloric, the nitric, the sul- 
phuric, the acetic, the tartaric, and the citric, any 
one of which will produce direct and rapid corrosion 
of the dentine, even when unaided by the temperature 
of the mouth. For a fuller and more explicit pres- 
entation of the points here briefly hinted at. see 



EXCITIXG CAUSES OF CARIES. 63 

Appendix at the close of this volume, Sec. A. These 
acids are often administered by physicians without 
any regard to their nature or their influence upon the 
teeth. Sometimes, however, they are given through 
a tube, though this method generally does not amount 
to much as a precautionary measure, for in most in- 
stances the fluid comes in contact with all parts of 
the mouth. A subsequent rinsing of the mouth with 
water effects only a dilution, not an 'entire removal 
of the acid. In order wholly to counteract their in- 
jurious influence upon the teeth, an alkaline solution 
should be used after the administration of such 
medicines. 

Galvanic action is a cause of- decay of the teeth, 
only so far as it is a means of decomposing com- 
pounds in the mouth, and the elements of which, 
according to the laws of affinity, form other com- 
pounds prejudical to the teeth. The elements hy- 
drogen, nitrogen, and oxygen, may thus be set free 
from animal and vegetable substances, when they will 
at once seek other elements with which to combine ; 
and the character of the combinations will be deter- 
mined by the nature of the elements, and by the 
attendant circumstances. These compounds will fre- 
quently be of an acid character, or contain acid. 

Such an arrangement may exist as will maintain 
a constant galvanic action, whose legitimate effects 
will be as constant upon the teeth ; and this cease- 



64 CARIES OF THE TEETH. 

less process cannot but make its mark. Tt is a 
favorable arrangement for galvanic action when there 
are two or three kinds of metals in the mouth at 
once, particularly if these are such as differ in their 
affinities for oxygen, and in their electric conditions. 
In some cases three or four kinds of metals are 
employed in filling teeth of the same mouth ; in 
some, fillings of one metal and a plate of another; 
and in others, plates of so low a carat are used that 
they oxidize rapidly in the mouth without the aid 
of any other metal. 

Comparative Liability to Decay. 

All classes of teeth are not alike liable to decay 
Their difference in this respect may arise from a 
dissimilarity in their organic structure, the best or- 
ganized being the most capable of resisting disease ; 
or from a concentration of the destructive agency 
upon the tooth first affected. The first molars are 
much more liable to decay than any other teeth, 
since they are less perfectly developed than those 
formed at a later period of life. They are the first 
permanent teeth erupted, and are subjected to all 
the irritating conditions consequent on the removal 
of the temporary, and the development and eruption 
of the permanent teeth. But these conditions in 
many cases produce no apparent injury upon them T 



COMPARATIVE LIABILITY TO DECAY. 65 

they maintaining their integrity till all the other 
permanent teeth appear, and then decaying earlier 
than any others. In such cases, the decay is a result 
of influences more potent than those occurring on the 
eruption of the other teeth. 

After the first, the second molars are most subject 
to caries, and after these the second bicuspids. The 
latter two classes, doubtless, are so subject more 
from the facility they afford to the lodgment of dele- 
terious substances than from a relatively imperfect 
organization. Besides, from six to fifteen years of 
age the teeth are less appreciated and less cared for 
than at a later period of life. The next most liable to 
decay, are the third molars. Then follow in order the 
first bicuspids, the lateral incisors, the central incis- 
ors, and the cuspids. Herewith are appended in tabu- 
lar form nearly one thousand cases of decayed teeth, 
as observed under ordinary circumstances, exhibiting 
the number and per cent, of these in each class : 

26, or 2-| per cent., in central incisors. 
28, or 2| " in lateral incisors. 

' in cuspids. 

in first bicuspids. 
134, or 13^ " in second bicuspids. 

370, or 37 in first molars. 

218, or 22| " in second molars. 

102, or lOf " in third molars. 

Of these, a large proportion were removed for re- 
lief from disease originating in caries of the dental 

5 



66 CARIES OF THE TEETH. 

tissue. In general, the superior teeth are liable to 
decay earlier and more rapidly than the inferior. 

Consequences of Caries. 

It is here proposed to refer only to some of the 
more common results of this affection. One of the 
most obvious of which is the exposure of the pulp 
of the tooth, on which exposure disease ensues, and 
finally death. During this diseased condition of the 
pulp there occurs that very peculiar and well-known 
sensation commonly denominated toothache. As well 
as the destruction of the pulp, the entire destruction 
of the crown of the tooth is the inevitable conse- 
quence of caries, unless arrested in its progress. After 
the destruction of the pulp and the lining membrane, 
the external periosteum in many cases becomes in- 
volved, the affection being but an extension of that 
which destroys the internal periosteum. Inflamma- 
tion and suppuration are of common occurrence, by 
which a discharge is established from between the 
margin of the gum and the neck of the tooth, or 
through a fistulous opening in the process and the 
gum, as is the case when an abscess is formed at the 
point of the root. 

A diseased condition of the alveolar process is in 
many instances produced by diseased and dead 
teeth, necrosis and exfoliation of considerable portions 



CONSEQUENCES OF CARIES. 67 

being sometimes the result. Indeed, extensive caries 
of the jaw is occasionally thus produced. Disease 
of the antrum, too, is very generally induced or 
greatly aggravated by the same cause. Tumors, 
sometimes of a malignant character, connected either 
with the bony or with the soft parts, not unfrequently 
spring from this source, particularly in constitutions 
of a cancerous diathesis. Great nervous derange- 
ment may result, either in whole or in part, from de- 
cayed teeth, as does very frequently facial neuralgia, 
which is sometimes confined to a single nerve-branch 
in the immediate vicinity of the irritating cause, 
sometimes ramified over the whole side of the face 
and head, and occasionally spreads much farther, so 
as even to implicate the shoulder and the arm. Neu- 
ralgia of these, extending down to the hand, is often 
found to be instantly relieved by extraction of a dis- 
eased tooth ; and any operator of much observation 
can call to mind numerous instances in which facial 
neuralgia has been thus relieved or wholly cured. 
This affection of the face, however, does not always 
originate in diseased teeth, though there is little doubt 
that in a majority of cases it arises wholly or partially 
from this cause. 

Inflammation of the mucous membrane of the 
mouth is a common result of diseased teeth, and it 
is liable to extend to distant parts of this mem- 
brane, and occasion greater difficulty than in the 



68 CARIES OF THE TEETH. 

mouth, as would especially be the case when there is 
an irritable condition of the throat and bronchia; and 
the oesophagus and stomach are not exempt. In what 
degree such an implication of the respiratory and 
the digestive apparatus is referable to diseased teeth, 
it may not be easy to determine, but it is impossible 
that a number of such teeth, involving in their 
disease all the ramifications of the facial nerves and 
the whole mucous membrane of the mouth, could 
remain there with impunity. And besides this direct 
influence on the lungs and stomach, diseased teeth 
are constantly emitting offensive odors, which are 
taken in by inhalation, and offensive matter which 
is swallowed with the food. 

Treatment of Caries. 

In the rational treatment of caries the first con- 
siderations are the nature and peculiarities of the 
obvious predisposing causes ; whether these are con- 
stitutional or local, and if constitutional, whether 
they are such as can be modified by therapeutic 
treatment of the general system. If the latter, such 
treatment should be adopted as will bring about the 
most perfect state of health, so as to obviate as far 
as possible all conditions favorable to decay, by se- 
curing a healthy condition of the mouth in all its parts 
— as the gums, the mucous membrane, and the sali- 



TREATMENT OF CARIES. 69 

vary glands. The teeth should be kept free from all 
deposits and accumulations of whatever character; 
for, though some of these may not affect the teeth 
directly, yet they induce disease of the surrounding 
parts, and thus indirectly exert a pernicious influence 
upon them. 

The foregoing remarks, however, refer rather to 
the prevention of decay than to its treatment after 
it actually exists. Yet they are on that account none 
the less important, since here, as elsewhere, preven- 
tion is better than remedy. But they apply to such 
prevention as well after decay has commenced as be- 
fore, if the ultimate object is preservation of the teeth. 
After the first attack the teeth are more vulnerable 
and less capable of resistance. 

When decay has attacked a tooth, the treatment 
indicated depends upon the nature and extent of the 
disease. Rapid decay requires more prompt and 
energetic treatment than that of slow progress. 
Remedies appropriate and efficient in the one are 
quite inapplicable to the other. The persistence of 
caries is not always in proportion to its rate of prog- 
ress. We sometimes find teeth in which the decay 
is not advancing rapidly, and thence are led to con- 
clude that it may be easily arrested ; the affected 
part, if superficial, is easily removed, and the dentine 
thoroughly polished ; and yet, after a time, decay 
again attacks the tooth at the same point. Or, where 



70 CARIES OF THE TEETH. 

the caries has penetrated the tooth, so that it requires 
filling, though it is skilfully done, and the plug and 
tooth' carefully polished, yet in many instances the 
dentine soon softens about the border of the filling. 

The extent and nature of the decay will suggest 
the mode of treatment. Superficial caries on some 
parts of the teeth may be remedied and removed by 
cutting away the portion implicated in the disease, 
dressing with a fine file, polishing with Arkansas, 
Scotch, or rottenstone till the file-marks disappear, 
and then applying the buff with rouge or oxide of tin, 
very thoroughly to the entire surface operated upon. 
Afterward, the most careful attention to cleanliness 
is requisite, to prevent a recurrence of the attack. 
This treatment is applicable to decay upon proximate 
surfaces ; but in the depressions of the masticatory 
and buccal surfaces of the molars, it is not practicable. 

Sometimes the dentine, at points where it is ex- 
posed, gives warning, by acute sensitiveness, of threat- 
ened decomposition, before there are any other 
indications of it, thus evidencing the presence of 
some very irritating agent promotive of decay. Such 
points should receive prompt and strict attention, 
and the increased sensitiveness be immediately sub- 
dued ; as it may be by the use of some preparation 
that will counteract the exciting influence — some 
dentifrice or lotion containing an alkali ; or rubbing 
the sensitive surface with a steel burnisher will in 



TREATMENT OF CARIES. 71 

many cases effect this object, and prevent the devel- 
opment of decay. Nitrate of silver is sometimes used 
for this purpose, and occasionally proves very effi- 
cient ; but its general use for such cases is of doubt- 
ful propriety, and when used, it should be with dis- 
crimination and caution. 

It has been suggested that the character of caries 
may be modified by the local application of thera- 
peutic agents — that the rapid decay may be changed 
to the slow, and this, too, without regard to the at- 
tendant circumstances, such as the condition of the 
secretions of the mouth, the causes producing the dis- 
ease, etc. For this purpose various agents have been 
proposed. It is held that by an application of the 
nitrate of silver, the white, rapid decay being changed 
to that of a dark color, is arrested in its progress. 
Bat there is no very palpable principle on which this 
agent can be supposed to operate to arrest caries. It 
is generally conceded to be injurious to a healthy 
tooth ; how, then, it becomes beneficial to one de- 
cayed, it is not easy to perceive. The notion may 
have originated in the fact that after the application 
of nitrate of silver, the dentine to which it has been 
applied turns dark, or black ; and this color being 
naturally associated with the slow form of decay, it 
may have been concluded that it might be thus asso- 
ciated by artificial means. This conclusion, however, 
is fallacious ; for the coloring matter being the oxide 



72 CARIES OF THE TEETH. 

of silver, deposited on the walls of the cavity, is 
wholly foreign, and holds no necessary relation to the 
kind of decay, or to the agent producing it. The 
deposit may possibly serve as a temporary shield to 
the dentine beneath, but only temporary ; whereas, 
on the other hand, it will be remembered that nitric 
acid is liberated by the decomposition of the nitrate, 
and operates destructively upon the tooth-bone. An 
ethereal solution of the terchloride of gold has also 
been suggested as a preventive application. Its oper- 
ation would be much the same as that of the nitrate of 
silver, and equally inefficient.- Preparations to neu- 
tralize and counteract the effects of deleterious agents 
upon the teeth have been recommended as topical 
applications. These are such as possess alkaline 
properties. But anything of this kind would require 
frequent application ; indeed, it would be necessary 
to keep the. affected part constantly under its influ- 
ence, as long as the surrounding conditions continued 
to favor decay. 

Though nothing of this kind can be relied upon 
permanently to arrest caries, yet, in many instances, 
much benefit is to be derived from local treatment. 
Alkaline topical applications will in many cases 
alleviate the most acute sensitiveness of the dentine, 
accomplishing this, no doubt, by their neutralizing 
influence upon the irritating agents. Many opera- 
tors employ simply the bicarbonate of soda for this 



TREATMENT OF CARIES. 73 

purpose, with the happiest results. As another class 
of topical applications to check or modify caries, 
those have been suggested which will form an insol- 
uble compound with the gelatinous or animal portion 
of the tooth ; such as tannin, creosote, and some of 
the essential oils. The only effect of these, however, 
is to form a shield or protection over the structure 
beneath : there is, of course, no change effected in 
the conditions or agents which produce decay. 



CHAPTER III. 

GENERAL REMARKS OK FILLINO 

The importance and value of the operation of filling 
teeth are obvious, from various considerations. It is 
one that is in frequent requisition. It is the only 
treatment for deepseated caries. By it the disease is 
arrested and the lost part restored, so far, at least, as 
it can be by a foreign substance. There is no material 
similar to that destroyed — no substance possessing the 
characteristics of the lost portion of the tooth, with 
which to effect the restoration. Under favorable cir- 
cumstances, the operation of filling is efficient in ar- 
resting caries, and restoring, to a greater or less extent, 
the lost portion of the tooth. In order, however, that 
it be permanent in its character, the case needs to be 
attended with favorable conditions, and the work to 
be thoroughly done. But two similar operations, both 
equally well performed, may result very differently as 
to ultimate success in preserving the teeth to which 
they may have been applied ; the one effectually pre- 
venting further decay, and the other seeming to inter- 
pose to it but little obstacle. Indeed, the probabilities 
of such success in different operations, equally well 



GENERAL REMARKS ON FILLING. 75 

accomplished, cannot be calculated without considering 
a variety of circumstances, such as differences in con- 
stitutions, in states of health, in previous and subse- 
quent habits. 

Filling teeth is predicated upon the nature of decay, 
upon the fact that the lost portion will not be restored 
by nature, and upon the fact that caries is an effect of 
external causes, and not of any cause within the tooth 
itself. If the causes of caries were alone within the 
tooth, then filling would not be its rational treatment. 
The organic structure of the teeth is of such nature 
that no change to the extent of decomposition will 
take place in it independently of external influences. 
Any organ or structure susceptible of becoming dis- 
eased by any cause resident within it, usually possesses 
the power of recuperation, and, in many instances, 
that of restoration also ; and if dentine could be decom- 
posed without external agents, the introduction of any 
foreign substance whatever into the cavity would cer- 
tainly not arrest the decay, but most probably accele- 
rate it. If it is true that decay of the teeth ever 
originates in constitutional causes alone, then the treat- 
ment should be constitutional, and not local. 

Filling teeth, then, is based upon the inability even 
of healthy dentine to prevent the occurrence of decay. 
As preliminary to the operation, all the circumstances, 
both direct and collateral, should be carefully noted 
in every case, and the course of treatment should con- 



76 GENERAL REMARKS ON FILLING. 

form to the indications thus observed. The constitu- 
tion, temperament, and health of the patient ; the 
peculiarities of the teeth ; their susceptibility of decay ; 
their present condition, and that of the parts about 
them ; the periosteum, the gums, the mucous mem- 
brane, the secretions of the mouth, the saliva, and the 
mucus, should all be closely considered ; for only on a 
correct diagnosis can a j)roper treatment be based. 
Every operation should be performed as completely 
as, under the circumstances, it is possible. Indeed, 
every step in the operation should be perfect, before a 
succeeding one is attempted. All the instruments em- 
ployed should be unexceptionable in material, form, 
and condition ; inferior instruments should find no 
place in the case of the dental operator. The material 
for filling should be of the best quality, and prepared 
in the best possible manner. Not that material for 
filling should be prepared in only one way ; for some 
materials, gold, for instance, may be prepared in many 
different forms, each perfect in its kind, and efficient 
in the hands of the expert manipulator. While with 
instruments and materials all irf the most perfect con- 
dition, and with a thorough cognizance and appre- 
ciation of all the attendant circumstances, our most 
skilful operators barely attain success, need we be as- 
tonished that the man ignorant of all these circum- 
stances, and possessed of only a few crude, ill-condi- 



GENERAL REMARKS ON FILLING. 77 

tioned instruments and materials, the nature of which 
he does not understand, fails in almost every attempt ? 

Much depends on therapeutic treatment; not, in- 
deed, to restore parts already lost, or to restore to 
health parts much diseased, but to avert a tendency 
to disease in parts but feebly organized. This treat- 
ment may be either constitutional or local, or both, 
bat constitutional when there is indicated any idio- 
syncrasy favorable to decay. If, however, the whole 
difficulty is local, topical treatment only is required. 
What the special treatment should be in either case 
wdll be more fully considered hereafter. Compara- 
tively little can be accomplished by local applica- 
tion to the substance of the tooth, but the parts con- 
tiguous, as the gums and the mucous membrane, 
may be thus treated with an assurance of more signal 
results. 

Though in the teeth nature does not assist to restore 
a lost portion, as in those parts more highly organ- 
ized, yet, to compensate in some degree, the destruc- 
tive process is far less rapid in the former than in 
the latter. The general surgeon depends much upon 
nature for the success of his operations, for, though 
he performed them unskilfully, yet the kind energy 
of nature is always present to assist him, but in this 
specialty the practitioner must necessarily depend 
more upon his skill, and less upon the curative efforts 



78 GENERAL REMARKS ON FILLING. 

of nature, though much more reliance is placed upon 
it now than formerly. 

Materials for Filling. 

In the selection of materials for filling teeth there 
are some important considerations that should be 
kept constantly in view ; the first and principal of 
which is to choose that kind which will protect the' 
tooth from further decay — protect the affected part 
against the influence of those agencies on which the 
disease depends. A material or class of materials 
should be selected that would not, under any cir- 
cumstances, induce either a local or a constitutional 
injury. 

There are several properties that materials for 
filling teeth should possess, one of the most impor- 
tant of which is, 

Indestructibility. — Any substance, whether simple 
or compound, that will not maintain its identity and in- 
tegrity when subjected to any conditions of the mouth, 
is unfit to be used as a material for filling. If com- 
pounds are employed, they should be such as would 
not be affected by the secretions of the mouth, or by 
any attendant conditions. A mere mechanical mix- 
ture would not be an appropriate material for per- 
manent filling, and all compounds of the metals, so 
far as we are familiar with them, are unfit for this 



MATERIALS FOR FILLING. 79 

purpose by reason of the facility with which they are 
changed in the mouth. The next most important 
property of a material for filling is, 

Adaptability. — By which is meant a capability of 
being wrought into suitable shapes for the purpose, 
— a facility of being applied and conformed to the 
parts upon which it is to be placed. There are sub- 
stances that would be entirely indestructible in the 
mouth, and that would be very desirable in other re- 
spects as materials for filling, that are yet altogether 
worthless for this purpose from lack of adajDtability. 
Quartz, if it possessed this property, would be valu- 
able as a material, but as yet there has been discov- 
ered no method of pre23aring it in an available form. 
On the other hand, many things possess the property 
of adaptability that are lacking in some other impor- 
tant particulars. The next important property is, 

Hardness. — A material may possess all the other 
suitable qualities and yet be too soft. A material 
should be hard enough not to be broken or worn away 
by any pressure or friction liable to be applied. This 
property is especially desirable for fillings in the mas- 
ticatory surfaces of the molars and bicuspids. It 
would, however, be admissible to employ a softer ma- 
terial for filling cavities in the proximate surfaces of 
the teeth, provided it would perfectly exclude all for- 
eign substances. 

Non-conductor. — Again, a material should be as 



80 GENERAL REMARKS ON FILLING. 

nearly as possible a non-conductor of heat, particu- 
larly for filling sensitive teeth, or those liable to be- 
come so under the influence of slight causes. Great 
variations of temperature will in most instances aggra- 
vate sensitiveness, and, in susceptible cases, produce it; 
and if the irritation is continued, the result may be 
fatal to the tooth. Gold, which possesses the largest 
number of desirable qualities as a material for filling, 
is in this respect very defective, being one of the best 
conductors of heat. To obviate this defect, some non- 
conducting material may be employed between the 
gold and the sensitive portion of the tooth. The pulp 
is liable to be affected by sudden and great changes of 
temperature, transmitted to it through a gold plug. 

Cohesion. — In the next place, a material should be 
susceptible of being welded or united into a solid mass. 
The permanency of an operation depends very much 
upon this quality. A filling having the different pieces 
which compose it perfectly united, will be much more 
durable than if effected with a material in which this 
cohesive property is lacking, it can be made with 
greater facility, and will be better and longer retained; 
and mainly because such a filling cannot be destroyed 
piecemeal. Non-cohesive material is retained by the 
general form of the cavity, which is to be shaped so 
as to bind all the pieces together, and thus hold them 
in place ; but a substance that will weld requires only 
two or three good retaining points, angles, or pits, pro- 



MATERIALS FOR FILLING. 81 

perly situated, in order to be firmly and permanently 
fixed in a cavity of any form. 

Color. — Another desirable property of material for 
filling is sncli a color as shall best harmonize with 
that of the teeth, particularly if they are in front. In 
this respect all the metals are objectionable, though 
gold is probably less so than any of the others, the 
objection to this being not so much in its color as in 
its lustre ; which objection, however, may be partially 
obviated by the kind of finish given to the work. In 
teeth of certain shades — semi-transparent bluish-white, 
for instance — gold, for exposed fillings, is very objec- 
tionable, indeed, in some cases, almost as unsightly as 
the absence of the tooth ; and in such instances, the 
darker metals would of course appear much worse. 
For such teeth, some substances, having more nearly 
the color of the teeth, would be the more desirable. 

Most of the materials employed for filling are me- 
tallic ; only a few non-metallic substances have been 
used, and these rather by the way of experiment, and 
for temporary purposes, than with any hope of perma- 
nent results. Of the metals, gold possesses more of the 
indispen sable properties than any other ; but the fol- 
lowing have been used for filling : lead, tin, silver, pla- 
tinum, gold, and amalgam. In the preparation of the 
latter, gold, silver, platinum, tin, bismuth, antimony, 
cadmium, zinc, copper, and mercury are employed. 

Lead. — This metal, in the early history of the 



82 GENEEAL EEMAEKS ON FILLING. 

profession, was used to some extent for filling teeth, 
though it possesses but few of the requisites for that 
purpose. The principal quality which recommended 
it is its adaptability ; but it is quite too soft for per- 
manent fillings in the masticating surfaces of the 
molars. It is easily wrought into foil and welded 
into mass in the cavity, but it is rapidly worn down 
by mastication, and its integrity readily impaired by 
the influence of some conditions of the mouth ; much 
more readily, indeed, than that of tin or silver. Acetic 
and some other acids act upon it with considerable 
energy in the mouth. By exposure to air and moist- 
ure, it is soon coated with carbonate or j3rotoxide of 
lead ; and this change is effected much more readily 
in the mouth. Lead is also objectionable in color, es- 
pecially for fillings in the anterior teeth, it being 
darker than the other metals employed for the pur- 
pose. It is a less perfect conductor of heat than some 
others that are in far more extensive use. 

Tin. — This metal has been, and is even yet, much 
employed as a material for filling. It is easily 
wrought into foil, and in that condition is readily 
adapted to the purpose, by reason of its softness and 
pliability. Fillings can be made with it in all cases 
in which non-cohesive gold foil can be used, to much 
of which, indeed, it can by skilful manipulation be 
made superior in cohesive property. Its equality, 
however, is greatly dependent on the manner of its 



MATEEIALS FOR FILLING. 83 

manufacture. It is harder than lead, and in many 
cases hard enough for permanent fillings ; it is fre- 
quently retained in crown cavities of the molars, ef- 
fectually preserving the teeth for many years. In 
favorable conditions of the mouth, it is not materially 
changed, not oxidizing easily, and not readily uniting 
with any substances liable to be brought in contact 
with it. But in an unhealthy mouth, with the secre- 
tions in an abnormal condition, and the teeth neg- 
lected, tin fillings are' very rapidly destroyed by the 
action of the various agents that may come in contact 
with them. Such a change may take place in the 
mouth as will in a little time destroy tin fillings that 
had long remained in good preservation ; and hence 
this material is not entirely reliable in any case, since 
such change may at any time occur. Some cases 
seemingly favorable to its use are found, on examina- 
tion, to be otherwise; and in almost any mouth in 
which there is a large proportion of mucus secreted, it 
cannot be depended upon for permanency. Its color 
renders it unfit for the anterior teeth. It is a less per- 
fect conductor of heat than gold, on which account it is 
frequently employed where the latter metal cannot be. 
There are cases in which it is not proper to use tin in 
connection with gold, or any metal having a marked 
difference of affinity for oxygen, in the same cavity. 
This applies in cases in which cleanliness is not ob- 
served, or where there is a general acid state of the 



84 GENERAL REMARKS ON FILLING. 

mixed saliva, and where there is a disposition to gal- 
vanic action. In the more favorable cases, however, 
it may be employed to fill the interior of large cavi- 
ties, placing upon it a covering of gold. 

But some of the plastic materials, as now presented, 
are better for this purpose than tin. Some have used 
tin foil mixed with gold foil for filling, the tin coming 
to the surface equally with the gold, it is claimed 
that rarely, if ever, do any unfavorable changes oc- 
cur. Dr. Abbott of Berlin has been a strong advo- 
cate for this mode of practice. The use of this ma- 
terial should be determined by the constitutional pre- 
disposition of the patient and the character of the 
teeth, which should be dense and well organized, in 
order to render it practicable. It is frequently very 
valuable for filling the temporary teeth, and for tem- 
porary use in the permanent teeth. 

Silver. — This metal, in the form of foil, has never 
been used for filling teeth except experimentally. It 
is not for this purpose superior to tin in any particu- 
lar, except in being somewhat harder; and in some 
particulars it is inferior, being quite as destructible in 
the mouth ; more easily affected by certain agents, 
such as nitric acicl, nascent chlorine, etc. ; less pliable 
and less adaptable ; more difficult to work into foil ; 
not so readily formed into fillings ; and possessed of 
much less cohesiveness, being almost unweldable by 
the ordinary method of manipulation. Silver is a 



MATERIALS FOR FILLING. 85 

better conductor than tin, and would therefore in many 
cases be more objectionable. The saliva is often in 
such a condition as to act upon it with rapidity. Its 
color, too, is objectionable. Having these disadvan- 
tages, its use has very properly never been adopted. 

Platinum. — This metal has been but little used for 
the purpose of filling, though it possesses some of the 
requisite qualities in a very high degree ; as, for in- 
stance, indestructibility, in which property it is supe- 
rior to gold. In other respects, however, it is very 
deficient; it has not as yet been wrought into any 
form in which it can be welded with facility; it is 
difficult to work into foil, and when it is put into this 
form, it possesses a stiffness and harshness that render 
its adaptation and condensation almost impracticable. 
It is more on this account, perhaps, than on any other, 
that it has been so little employed for the purpose of 
filling. It has also less cohesiveness than gold, and 
much sooner parts with this property. Slight crump- 
ling or bending serves to stiffen it, so as to destroy its 
applicability. Good fillings may be made of well- 
prepared platinum sponge, recently annealed. It re- 
quires skilful manipulation, however, for the least 
moisture destroys its cohesive property entirely. It 
is a good conductor of heat, and on this account objec- 
tionable. In the respect of color, too, it is undesirable. 
Platinum should never be placed in close proximity 
to tin fillings, or to gold plate or clasps of low carat. 



86 GENERAL REMARKS ON FILLING. 

It is, however, being employed to some extent in con- 
nection with gold, which in some respects seems to 
serve a valuable purpose. It is used in the form of 
foil, of any desired thickness, heavily coated with pure 
gold. The claims for this combination are, that a far 
harder and more resistant filling can be made than 
with gold alone, and a modification of the color of the 
gold that is far preferable for teeth of certain shades 
of color. 

Gold. — Of all the metals that have as yet been used 
for filling teeth, gold possesses more of the requisite 
properties than any other, and sufficiently so for all 
practical purposes. Twenty-carat gold is very seldom 
affected by any agencies with which it is brought in 
contact in the mouth ; pure gold never. In the filling 
of teeth, there are two objects to be aimed at : one, a 
sufficient hardness to withstand the wear of mastica- 
tion ; the other, a thorough protection to the cavity 
against all decay-producing agents. For the attain- 
ment of the first of these, gold is not all that could be 
desired ; yet it is, perhaps, as efficient in this respect 
as any other metal that can be employed. But the 
second object, gold, when well manipulated, accom- 
plishes very effectually : that is, so long as the filling 
maintains its integrity ; after it is partially worn out, it 
thus far fails, of course. In adaptability, too, gold is 
superior to any other metal. It can be wrought into 
a variety of forms, with any of which very good fill- 



MATERIALS FOR FILLING. 87 

ings can be made. It can be perfectly conformed to 
any shape of surface, however irregular. A tooth that 
can be filled at all, can be filled with gold. This as- 
sertion was made a number of years ago ; and if it was 
true then, it is much more true now ; for then the 
cohesive property of gold was not employed at all, or 
even recognized as available ; but now, this property 
has been rendered efficient and practicable. Then, our 
best operators did not aim to unite the different por- 
tions of gold of which the fillings were composed. The 
idea that such consolidation could be effected seemed 
never to have entered the mind of any one. Indeed, 
with the instruments, and the method of manipulation 
then employed, this cohesive property could not have 
been made available ; but as it came to be recognized, 
the instruments and the manipulations were adajDted 
to the purpose. Formerly, an ordinary gold plug 
when removed from a cavity could be readily separated 
into as many pieces as originally composed it ; but 
now, when cohesive gold is skilfully used, the mass 
composing a filling cannot be divided into its original 
parts, but may be wrought into plate, wire, or foil. 
Non-cohesive gold — the modification in which, till 
about the year 1859, it was always employed — would 
not weld, even under great pressure ; but in the mode 
in which it is now prepared, it will weld readily and 
thoroughly. There are certain requisites essential to 
this welding property of gold. If it is in the form of 



88 GENERAL REMARKS ON FILLING. 

foil, it should not present a smooth, planished surface; 
it must be annealed after hammering, in order that 
its ultimate particles may be in the best condition for 
cohering ; it must be entirely free from all deposits of 
foreign substances ; and it must be kept from exposure 
to the atmosphere. 

Gold is a good conductor of heat, and this is the 
chief objection to it as a material for filling. As to 
sensitive teeth this is a very serious objection, in some 
cases necessitating the employment of non-conducting 
material beneath it, and in others precluding its use 
altogether. The color of gold, however, is seldom an 
objection to its use, "though it sometimes renders it un- 
suitable for fillings in the front teeth. But this objec- 
tion has been already adverted to. 

Various Preparations of Gold. — And first, of the 
manufacture of gold foil. For this purpose pure gold 
is used, for procuring which various methods are em- 
ployed. But the most common of these are insuffi- 
cient for the production of gold absolutely pure. It 
is, however, deemed irrelevant here to detail the pro- 
cess by which this end is attained ; it is enough to 
premise that, for the manufacture of the best quality 
of foil pure gold is indispensable. The gold is cast 
into an ingot about an inch wide, is then placed be- 
tween a pair of rollers and milled down as thin as 
practicable, the piece, while in this process, being fre- 
quently annealed. It is then cut into squares, which 



MATERIALS FOE FILLIXG. 89 

are inserted with wooden pliers between vellum leases, 
a hundred and sixty or seventy in a pack. Over this 
pack two pockets are drawn, inclosing it completely. 
The pack is then hammered on a granite block with 
a hammer weighing twelve or sixteen pounds till the 
leaves are spread out to the full extent of the pack. 
They are then removed from the pack, cut into four 
sections, annealed, replaced in the pack, and again 
subjected to the hammer; this process is repeated till 
the desired thickness of foil is obtained. Much ex- 
perience and skill are requisite to the proper accom- 
plishment of this part of the work. By a single un- 
skilful stroke of the hammer a whole pack may be 
spoiled. 

Gold foil is numbered according to the grains con- 
tained in each leaf, ranging from 2 to 240. The most 
common numbers are 4, 6, 10, 20, 30, 60, 120, and 
240 — the latter two are seldom used. Of the smaller 
numbers, 4 and 6 are in most frequent use. It has 
heretofore been a desideratum to obtain gold foil per- 
fectly uniform in quality. This seems now to be al- 
most if not altogether attained by the more careful 
and skilful manufacturers. 

Crystal Gold. — This form of gold was introduced 
to the profession about twenty-eight years ago. Some 
experiments in this direction, indeed, had been made 
as early as 1825, by C. Ash, of London, and again in 
1850, by Dr. S. A. Main, of Xew York. Their prepara- 



90 GENERAL REMARKS ON FILLING. 

tions, however, were simply precipitates, and nothing 
more. But in 1853, Dr. A. J. Watts, of Utica, New 
York, obtained letters patent for this preparation of 
gold for filling teeth. This preparation was at first 
denominated sponge gold, hut after some modification 
received its present name. There are numerous for- 
mulas by which preparations of crystal gold may be 
made, but, so far as we are acquainted with them, they 
are all embraced in two general methods : the one to 
obtain simply a precipitate of the metal adaptable to 
the filling of teeth ; and the other, to combine this 
precipitate with mercury, and obtain a definite crystal- 
lization. For the preparation of the sponge or crystal 
gold the absolutely pure metal is required. This is 
dissolved in nitro-muriatic acid, the gold being added 
till the solution is saturated. Various materials may 
be used to precipitate it, the most common of which 
are sulphate of iron, and oxalic acid, the latter on some 
accounts being preferable. The character of the pre- 
cipitate will be determined, in a great degree, by the 
manner in which the precipitant is added ; if slowly, 
the precipitate will take a more definite form, inclining 
to the crystalline or fibrous. 

A preparation may be made by introducing the 
precipitant gradually, and then carefully washing the 
precipitate and heating almost to redness. For per- 
fect crystallization of the gold, combine the precipitate 
with from six to twelve times its weight of pure mer- 



MATERIALS FOR FILLING. 91 

cury; let it stand a short time, subject to a gentle 
heat, and then remove the mercury with dilute nitric 
acid. Afterward wash the nitrate of mercury from 
the gold ; place the latter upon a slide, and bring it 
to a full red heat in a muffle, and the gold is then in 
a condition to be used for filling. This is about the 
formula upon which a patent was granted to A. J. 
Watts. The preparation possesses some advantages 
over gold foil. It is as readily introduced ; it is more 
capable of thorough consolidation ; it has, besides the 
cohesiveness of foil, the additional property of inter- 
lacing its crystals one with another, by which property, 
even without cohesion, the pieces of a filling can be 
firmly united, and it takes a better hold upon the 
walls of the cavity, to which it presents the angles and 
ends of the crystals, so as to be more thoroughly 
adapted and fastened. 

Amalgam.-— By this term are designated all those 
preparations formed by a combination of mercury with 
various other metals ; most frequently with silver and 
tin, but occasionally with gold, platinum, bismuth, 
cadmium, zinc, and lead. The several formulas for 
amalgam need not here be specified. The kind most 
in use is prepared by melting together and carefully 
mixing pure tin and silver, filing this mixture, when 
cooled, into dust, combining the latter with mercury 
in sufficient proportion to give the requisite plasticity, 
and then thoroughly washing the whole in alcohol or 



92 GENERAL REMARKS ON FILLING. 

boiling water, to remove the oxides formed during the 
combination of the metals. If there is a redundance of 
mercury, it may be removed by pressing the paste in a 
piece of chamois skin. This preparation may in some 
'cases be used for filling with considerable success ; but 
in no case can it be relied upon as a durable material, 
its destructibility being no less than that of tin or sil- 
ver in any circumstances, and being greater where all 
the excess of mercury is not removed from the surface 
of the filling, and the surface not burnished down solid 
and smooth. Mercury oxidates with considerable 
rapidity when exposed to air and moisture, and with 
increased energy under the influence of heat, espe- 
cially when some acid is present. This facility of 
oxidation is still increased when other metals are 
combined with mercury. Oxidation of such fillings 
will in some cases be confined to the surface, wherever 
there is contact of moisture ; in others, it will pervade 
the whole mass, rendering it black and spongy through- 
out. 

Amalgam fillings, in a short time after their inser- 
tion, undergo a hardening process, occasioned by crys- 
tallization of the mass, as well as by evaporation of the 
mercury. The consequence is, either that the mass 
becomes porous, or that it contracts; the former, doubt- 
less, in cases where the oxidation extends through, 
and the latter where it is confined to the surface. 
When a filling is in either of these conditions, the pre- 



MATERIALS FOE FELLING. 93 

servation of a tooth is very uncertain. On removing 
an ordinary amalgam filling that has been worn for 
some time, its entire surface will generally be found 
oxidized ; and a tooth filled with this material gener- 
ally becomes blackened, and its appearance ruined. 

To such objections against this material, another 
is to be added in cases in which there are fillings or 
plate of platinum or gold: galvanic action will often 
be established, in a degree proportionate to the prox- 
imity and extent of surface of the metals and the con- 
dition of the secretions. This may occasion much 
mischief. Some constitutions are very susceptible to 
the influence of mercury ; and a gradual decomposi- 
tion of several amalgam fillings in the mouth may 
seriously impair the general health. Therefore, before 
this material is employed, the health, temperament and 
habits of the patient should be carefully noted; for 
these and other circumstances may often indicate its 
inadmissibility. 

So great and so numerous are the objections to this 
material, that it is wholly discarded by some in the 
profession, and but sparingly used by a great many 
others. Its adaptability is the main property on which 
are based the arguments in its favor. It is easily ap- 
plied, and becomes very hard upon crystallizing. It 
is affirmed, also, that teeth which cannot be saved 
with anything else may be filled with this, and made 
valuable. This, however, is not true since the em- 



94 GENEEAL KEMAEKS ON FILLING. 

ployment of the cohesive property of gold, which 
quality renders this metal equal in adaptability to 
amalgam. 

Oxy-chloride of Zinc. — This preparation consists of 
oxide of zinc, and chloride of zinc in combination. 
As a plastic filling it has been extensively used, and 
when properly prepared, and rightly employed, with 
favorable conditions in the mouth, serves a valuable 
purpose. Such fillings are often found after many 
years use intact, so far as wasting is concerned, and 
affording absolute protection to the cavities in which 
they are placed. 

But these fillings will not withstand the attrition 
of direct contact in mastication. 

The oral secretions in some conditions are rapidly 
destructive to this material. It is one of the best 
materials for temporary fillings. A little experience 
renders its use easy. It effectually excludes all foreign 
substances, is a good non-conductor, and is only dis- 
placed by wear and the solvent power of the saliva in 
some vitiated conditions. Guilloi's Cement, and Ce- 
ment Plomb are preparations in all practical aspects 
similar to oxy-chloride of zinc. Some variation in the 
method of manipulating them is required. There is 
found some difference of susceptibility in these different 
preparations to the vitiated secretions of the mouth. It 
is a good protection to sensitive dentine, and in many 
cases for exposed pulp, under gold filling. It more 



MATERIALS FOE FILLING. 95 

nearly resembles the natural teeth in color than any 
other material that has been used for rilling. 

Oxy-phosphate of Zinc is being largely employed 
instead of the chloride. 

It is more permanent than the chloride in the secre- 
tions of the mouth, and withstands the wear of masti- 
cation, equally as well if not better, than the latter. 

To sensitive dentine, and even to exposed pulps, it 
is far more acceptable than the chloride, because of its 
non-irritant quality ; its direct application to highly 
sensitive tissue does not produce pain nor irritation : 
The chlorine in almost every instance when applied to 
such tissue produces intense pain. 

The Phosphate possesses the property of hardening 
in the saliva. 

Non-metallic Materials. — Of the non-metallic ma- 
terials employed for filling teeth there are not many 
worthy of any particular consideration. Indeed, 
gutta-percha and its preparations constitute the chief 
of these substances now used for this purpose, though 
some others have been employed. Gutta-percha is 
useful for temporary fillings, and, under ordinary cir- 
cumstances, is sufficiently durable. It is valuable 
for filling those teeth which it may be desirable to 
retain only a short time, or those in which it may be 
necessary temporarily to protect a sensitive part 
against the influence of irritating agents, in order to 
restore it to health. Gutta-percha is not readily do- 



96 GENERAL REMARKS ON" FILLING. 

composed by the fluids of the mouth, when they 
are in a healthy condition. In some instances we 
have known it worn in the mouth for years with but 
little change. But in the cavities on the grinding 
surfaces of the molars and bicuspids, it will not with- 
stand the wear of mastication a great while, though 
long enough in most cases to subserve the j)urposes of 
temporary fillings. It possesses great adaptability. 
By simply being warmed over a spirit-lamp or in 
boiling water, it becomes plastic, and is with great 
facility introduced and conformed to the cavity. It 
may be applied also in solution, being dissolved in 
chloroform till it approaches a pasty consistence, then 
used in a pledget of cotton, and introduced into the 
cavity, where the chloroform evaporating, leaves the 
gutta-percha as a filling. The only objection to this 
method is the contraction consequent on the evapora- 
tion of the chloroform. Another property that ren- 
ders this substance highly valuable, is its non-conduc- 
tion of heat, it being in this respect as nearly perfect 
as any other material employed. 

A preparation of gutta-percha with mineral sub- 
stances, known as Hill's stopping, has for many years 
been extensively used for temporary fillings ; indeed, 
it has superseded simple gutta-percha almost entirely. 
The aim of this preparation was to obviate two or 
three objections to pure gutta-percha; as, its contrac- 
tibility in the cavity, its softness and its color. The 



MATERIALS FOR FILLING. 97 

composition of Hill's stopping is as follows: With 
pure gutta-percha in a plastic state are mixed quick- 
lime two parts, and quartz and feldspar one part each, 
which latter are reduced to an impalpable powder, 
and kneaded into the mass as long as it will receive 
them without becoming brittle. Such is the formula 
given by the inventor of this preparation ; though it 
is presumed that one of these materials alone, namely, 
pulverized quartz, would be found entirely sufficient, 
since it is capable, by itself, of quite as much as is at- 
tained by all together. The addition of gold or pla- 
tinum fillings has been recommended ; but no advan- 
tage is thus gained. It was at first claimed for this 
material that it would serve for permanent filling ; 
but it was soon demonstrated to be insufficient, It 
was supposed, also, that it might be employed for par- 
tial fillings in large cavities, which could be completed 
with gold ; but for this, too, it was found impracticable, 
since it did not make a sufficiently firm foundation. 

This preparation is applied in the same manner as 
simple gutta-percha, being warmed on a porcelain or 
metal slab over a spirit-lamp till sufficiently soft, and 
then packed into the cavity. It cannot be employed 
in the form of solution, nor should it be softened in 
boiling water. It may be conveniently prepared by 
dissolving the gutta-percha in chloroform to almost a 
pasty consistence, then adding the mineral substances, 
and putting it into a vessel suitable for the evapora- 



98 GENERAL REMARKS ON FILLING. 

tion of the chloroform. It should be made so thick 
that the silex would not fall to the bottom. When 
HilVs stopping or gutta-percha is used, as soon as the 
cavity is filled an instrument with the end nearly as 
large as the orifice of the cavity should be placed upon 
the filling, and retained there with considerable pres- 
sure till the mass is cool. After cutting and dressing 
the surface of the filling as thoroughly as can be with 
instruments, then by passing over the surface a short 
camel's-hair brush, with chloroform, a very smooth 
surface and perfect finish will be made. In some re- 
spects, there is perhaps nothing better for temporary 
fillings than this preparation of gutta-percha. 



CHAPTER IV. 



INSTRUMENTS FOE FILLING. 



In describing the instruments for filling teeth, it 
will be convenient to take them somewhat in the order 
in which they are employed in ordinary practice ; first 
referring to those which are used for cutting away 
portions of the teeth, for the purpose of separating 
them, and for dressing off the borders of cavities ; then 
to those for removing decay and forming the cavities ; 
and finally to those for introducing, consolidating, and 
finishing fillings. The first, then, that claim our at- 
tention, are the 

Heavy Cutting-instruments. 

These are of chisel-shape. They should be of good 
steel, well wrought, and thoroughly tempered. Every 
step in the process of their manufacture should be 
most perfectly executed, so as to insure an edge that 
will cut not only dentine, but also enamel, which is 
the hardest animal substance. Various sizes of the 
straight chisel-form are required. 

They should be no thicker than is required for 
strength, they should be stiff, that there may be no 
springing or tremulous motion under the pressure they 



100 INSTRUMENTS FOR FILLING. 

are required to sustain. For separating front teeth, 
they must be thin enough to pass readily into the in- 

Fig. 3. 



tended space, and about one-fourth of an inch wide at 
the edge. But for separating bicuspids and molars, 
the instruments should be thicker and broader ; as, 

Fig. 4. 




thick, indeed, as the required space will admit. In 
some cases they should have the edge oblique, as in 
Fig. 5. 



Fig. 5. 




It is seldom that these instruments need any curve. 
The straight form is the best, unless, as rarely hap- 
pens, the point to be operated upon cannot be reached 

Fig. 6. 




efficiently with it ; as, for instance, in a small mouth, 
a slight anterior curve will be required in the shaft of 
the instrument, to facilitate its approach to the front 
proximate surface of a second or a third molar. Fig. 6, 



DRILLS. 



101 



a heavy instrument, with a sharp point and a lateral 
curve, is often efficient in opening up cavities and cut- 
ting down strong projections of enamel. Fig. 7 we 
consider as a very valuable form. Every operator 

Fig. 7. 




should have at hand a sufficient variety to meet every 
demand — about three sizes of each form. 

These instruments are now made with steel handles, 
much smaller than those represented above, and are 
used with a mallet. 

Fig. 8. 




The above (Fig. 8) will give an idea of the variety 

of sizes that are desirable. 



Deills. 



Bur Drills. — Of this indispensable class of instru- 
ment- there are various forms. They should be maim- 



102 



INSTRUMENTS FOR FILLING. 



factured of the beststeel, and wrought with the greatest 
care. After having been forged as near the proper 
size as possible, the bulb is shaped by dressing with a 
fine file, or, which is better, by turning in a lathe, 



Fig. 9. 



those made by the latter method being superior, and 
cutting much more smoothly ; they do not catch and 
jar as do those of less regular form. After the bulb 
is formed, it is cut with a sharp-edged file. 

Fig. 10. 



Of these drills, Fig. 9 represents a bur of a spherical 
form. Fig. 10 is cone-shaped, which may have various 
degrees of bevel, terminating in a sharp point. Fig. 11 
is of a cylindrical form, cut upon the sides and end. 

Fig. 11. 




Fig. 12 is in the. form of a wheel, cut upon the edge 
only, or upon both the edge and the end. The cutting 
upon all of these should be very regular and uniform. 
This should be made by machinery, though it is 



DKILLS. 103 

usually done by hand. Of these instruments, there 
should be a variety in size, the smallest considerably 
less than the smallest cavity the dentist ever attempts 
to fill — that is about one thirty-second of an inch in 
diameter, and the largest about one-fifth of an inch. 
Inclusive of these extremes, there should be fL\e or six 
sizes of each particular form. These instruments are 
used for opening cavities. With them a more regular 
and perfect orifice is made in small and medium-sized 
cavities than by any other method. They are also 

Fig. 12. 



used to some extent for forming the cavities, and even 
sometimes, in large cavities, for making retaining- 
points for a filling. 

The dental engine is now so generally used that the 
hand-drill, as shown in these figures, is seldom if ever 
used, but the points here shown are used with the 
engine. 

Some years ago, Dr. Scranton devised a rather pe- 
culiar kind of drill, and efficient withal. Its form is 
spherical, and in its manufacture the bulb is made as 
for the ordinary bur drill ; but, instead of having cut 
upon it numerous serrations, thus forming a series of 
sharp edges, a concave cut is made upon two opposite 
sides with a small round file. The instrument then 
presents two concave and two convex sides with four 



101 INSTRUMENTS FOR FILLING. 

sharp longitudinal edges; these may be so inclined 
as to cut only when rotated in one direction, or to 
operate alike well when rotated either to the right or 
the left. 

This instrument has two or three advantages over 
the ordinary bur ; it can be kept sharp with the oil- 
stone till it is almost entirely used up, and will conse- 

Fig. 13. 



quently last much longer, and will cut much more 
rapidly than the serrated bur. It is a very valuable 
instrument for operating upon firm, strong teeth. It 
is represented in Fig. 13. 

Common Drills. — Of other drills, Fig. 14 represents 
one with a square point, bevelled from both sides, 



Fig. 14. 



measuring from a half to a whole line in width, and 
attached to a small round shaft. The edges of the 
drills should be very hard, so that they may cut with 
the greatest celerity. Of this kind there should be 
about ten sizes, ranging in width from No. 12 to No. 
25 of Stubb's gauge. These are used mainly for form- 
ing retaining-points in cavities. 

Fig. 15 is the spear-shaped drill, the edges of which 



DRILLS 



105 



are formed by dressing from both sides, or, it may be, 
from only one, in which, case it will cut only when 
rotating one way. This shape is employed princi- 



Fig. 15. 




pally for drilling roots for filling, or receiving pivot- 
teeth. 

The burs and drills may be made of pieces of wire 
one inch and a half long, and fitted to a socket-han- 



Fig. 16. 




die that will accommodate a large number ; or, of a 
continuous piece of large wire. The latter is the pref- 
erable method, since much time is consumed in chang- 
ing them in sockets. The handles should be made 



106 INSTRUMENTS FOR FILLING. 

with six or eight sides, and cut on each alternate side. 
In the use of these instruments the drill-ring is almost 
indispensable. This is a ring used on the middle or 
index finger, with a socket attached, in which rests 
the end of the handle of the instrument. (Fig. 16.) 
The drill is rotated commonly with the thumb and 
fingers. 

Drill-stocks of various forms have been invented, 
with the view of increasing the motion of the drill, 
of augmenting its power, and especially of bringing 
it to bear upon points inaccessible to the straight in- 
strument. 

The use of the burs and drills bv the hand, and 
by means of the various drill-stocks, has been almost 
wholly superseded by the introduction and use of the 
dental engine. 

This appliance, in a far less perfect form than now, 
was introduced to the dental profession about the 
year 1870. 

Mr. Green, of Michigan, first introduced the pneu- 
matic engine ; succeeding this, was that denominated 
the " Morrison Engine." Within a short time after 
this, the suspension engine was devised and constructed 
by Dr. W. S. Elliott. 

This engine possesses some excellent qualities. Its 
steadiness of motion, freedom from tremor or back- 
lash, and the facility of use, are qualities that make it 
very valuable in these respects. When the large dress- 



ENGINES. 
Fig. 17. 



10; 




108 



INSTRUMENTS FOR FILLING. 
Fig. 18. 




ENGINES. 



109 



ing burs or polishing cones are being used it is superior 
to any other. 

The illustration on page 107 (Fig. 17) gives a cor- 
rect idea of the machine. 

Various other modifications of dental engines have 
from time to time been presented, a description of 
which is unnecessary here. That improved by, and 
bearing the name of S. S. White, is at present very 
popular ; it has now the most prominent position be- 
fore the profession ; other modifications, however, are 
highly esteemed by many. It is well represented by 
the illustration on page 108 (Fig. 18). 

This engine certainly possesses many desirable 
qualities. The facility of movement and adaptation 

Fig. 19. 




afforded by the flexible cable, and the hand-piece, seem 
to be about all that can be desired. The mode of at- 
tachment to and retention of the drills and other ac- 



110 



INSTRUMENTS FOE FILLING. 



cessories by the hand-piece, leaves little or nothing 
more to be desired in that direction. 

Attachments are made to the hand-piece by which 
drills are operated at a right angle with the shaft, and 
also at an acute angle, or with a backward inclina- 
tion to almost forty-five degrees. They are shown in 
Fig. 19. 

Some description and illustration of the instruments 
and appliances used with the engine might appro- 
priately be given here, but so numerous have they be- 
come that it is-impracticable to give more than a rep- 
resentation of each class. 



Fig. 20. 



Fig. 20 presents illustrations of the spherical and 
wheel burs, three sizes. Of each class of burs there 
should be eight or ten sizes ; it would also be well to 
have two or three grades, as respects fineness of cut ; 
the coarser wilh serve for rapid work, and the finer for 
the smooth and more perfect work. 

This variation may with propriety pertain to all 
forms of- burs used upon the teeth,, and those used for 
dressing fillings as well. 



BUES. 



Ill 



• Fig. 21 shows the cone and the inverted cone- 
shaped burs ; about the same variety in number and 
size will be required as of the spherical. 



Fig. 21. 




In Fig. 22 are presented the fissure burs, square 
and jDointed. 



Fig. 2: 



In Fig. 23 are shown the bud-shaped and oval 
burs. 

Fig. 23. 




In the following illustration are shown the flex- 



112 



INSTRUMENTS FOR FILLING. 



ible burs and drills for operations in canals of 
roots. 




Fig. 25 shows the spear, the square edge, and the 
spade-shaped drills, all flat ; and the twisted drill. 



Fig. 25. 




f) A 




The burs and drills here presented embrace all the 
principles that have been employed in the ordinary 
operations upon the natural teeth. 

Of the plug-dressing burs a large variety is made ; 
nearly the same general forms have been adopted as 
in those for operating in cavities of decay. 



DRILLS. 



113 



The following illustration gives the most common 
forms. 



Fig. 26. 




In the following is shown a set of burnishers for 
finishing fillings. 



Fig. 27. 




The following illustrates a set of corundum points, 
cones and disks for finishing fillings. 



Fig. 28. 




About the same forms and sizes of points for fin- 
ishing are made of Arkansas, Scotch, and Hindostan 
stones. These are all valuable, and should always be 

8 



114 



INSTRUMENTS FOR FILLING. 



at hand, and a sufficient variety of sizes to meet all 
cases. They are shown by Fig. 29. 



Fig. 20. 




Excavators. 

Of the small cutting-instruments for opening and 
forming cavities, and removing decay from them, 
there is a great variety, though a few general forms 
comprise the whole. Until within comparatively a 
short time, there has been no very systematic arrange- 
ment of these instruments, such as the convenience 
both of the profession and the manufacturers of dental 
instruments would seem to dictate. In a classification 
that we have adopted and found very convenient, 
they are arranged by numbers, the most simple being 
placed under the first, and under each successive num- 
ber a more complicated form. All the varieties are 
embraced in twelve numbers, which are represented in 
Fig. 30. These varieties are discriminated by the 
forms of the points, and their position on the shaft to 
which they are attached, and not by any curve which 
the shaft may have at any distance from the point. 



EXCAVATORS. 



115 



No. 1 has simply a flat point slightly curved, with 
a round edge transverse to the shaft. Four sizes will 
be sufficient for ordinary purposes. 



Fig. 30. 




No. 2 has a flat point with a short curve, bringing 
the point to a right angle with the shaft ; the edge is 
transverse. This differs from No. 1 in having the 
curve more short and abrupt, and the edge more 
nearly square. Of these there should be five sizes, 
with some variety of form. 

No. 3 has a flat point with a square transverse edge. 



H6 INSTRUMENTS FOR FILLING. 

which rises at a right angle from the shaft ; the blade 
being from one to two lines in length. Five sizes. 

No. 4 has a flat point, curved so as to be at a right 
angle with the shaft; the blade, from the centre of 
the curve to the edge, being from one to two lines, 
and the edge straight. Four sizes. 

In each of the foregoing the edges should expand 
slightly in width. 

No. 5 has a flat point with a square edge, which is 
parallel with the shaft, and rises at a right angle 
from it. The blade is from one-half to two and a half 
lines in length, and from one-half to one line in width, 
with no expansion at the edge. Six sizes, with some 
variety of form. 

No. 6 and 7 are right and left excavators, with flat 
points and double curves ; the first curve being at an 
angle of about twenty degrees, and the other lateral, 
right and left, reaching from the beginning of the 
first curve to the point. The length of blade is from 
one to three lines. Four sizes. 

No. 8 has a crescent-shaped point, the blade rising 
by a small attachment from the shaft, and making a 
right angle with it. The edge is a regular curve, de- 
scribing about two-fifths of a circle, and is parallel 
with the handle. The point should be perfectly 
formed. Six sizes. 

No. 9. The form of the point is the same as in No. 
8., the difference being in the position of the blade, the 



EXCAVATOBS. 117 

edge of which is transverse to the %haft, and rises 
from it at an angle of one hundred and thirty degrees. 
Six sizes. 

In No. 10 the point has the same shape as in Nos. 
8 and 9. The cutting edge is transverse to the shaft, 
and rises by a small neck at a right angle from it. 
Six sizes. 

Such are the most important forms of excavators,, 
though modifications will be required for particular 
cases. While Nos. 8, 9, and 10 are not in extensive 
use, a few operators have used them for some years, 
and prize them very highly. In many difficult cases 
they are far more applicable than any other instru- 
ment we have. For instance, in the formation of the 
cervical wall of a proximate cavity in any of the teeth, 
but particularly in the superior bicuspids and molars, 
there is no other instrument so applicable and efficient 
as No. 9 ; with it, that part of the cavity, so frequently 
neglected, is just as easily formed as any other. 

Cases will occasionally be presented in which some 
curvature of the shaft of the instrument will be requi- 
site. But no more curve should be given to any in- 
strument than may be absolutely necessary, for it is 
impossible to manipulate with the same precision and 
delicacy with curved as with straight instruments. The 
degree of curve necessary in any given case will be 
determined by the position of the decay on the tooth, 
and the location of the latter in the mouth. 



118 INSTRUMENTS FOR FILLING. 

The diamond point, as it is familiarly called, is a 
modification of No. 3, varying from it in that it has a 
sharp point instead of a square edge, and is three-sided 
from shaft to point, each angle being a cutting edge. 
This instrument is especially valuable for forming 
grooves or farrows within cavities, and for dressing 
the borders. 

After being much reduced by use, it may still be 
kept in form, and sharp, and used as a drill for mak- 
ing under-cuttings, for which it is very efficient. No. 
11 represents this instrument. 

A modification of No. 9, commonly known as the 
scoop or spoon-shaped instrument, is much used. The 
sharp corners of No. 9 are removed in this instrument. 
It is shown in No. 12. 

Since the issue of the second edition of this work, 
efforts have been made by several members of the pro- 
fession to arrange and systematize excavators into sets, 
that should embrace every desirable form and size. 
No one has as yet succeeded in producing that which 
meets the views of all operators. 

There is, perhaps, now more diversity of opinion and 
practice in reference to the use of hand excavators, in 
the preparation of teeth for filling, than ever before, 
from the fact that a great diversity of practice exists 
in reference to the use of the dental engine and its ac- 
cessories for this purpose ; some using these almost 
exclusively in the preparation of cavities ; others for 



EXCAVATORS. 



119 



this purpose making far less use of the engine, and 
more use of the hand excavators, claiming that with 
the latter muclj. more precise and definite execution 
can be attained. 

Fig. 31 presents an arrangement of excavators by 
Dr. I. J. Wetherbee, very good indeed so far as they 



« 



Fig. 31. 



// 



/f 



extend, and perhaps in the majority of cases they would 
quite suffice. 

Of the Manufacture of Excavators. — For making 
these instruments, the best cast-steel wire, No. 8, should 
be selected. This should be forged down so as to leave 
the end large enough to form the intended point. Nos. 
1 to 6 inclusive, Fig. 30, may be formed by forging, 
and afterward dressed up with the file. No. 8 to 12, 
inclusive, should be formed by the files out of a bulb 
left from the forge ; for this purpose different forms 
and sizes of files will be required, in order definitely 



120 INSTRUMENTS FOR FILLING. 

to shape all the angles and points. In heating steel, 
either for forging or tempering, a full red heat should 
in no case be exceeded, since a higher degree than this 
injures it. After the points are formed, and made 
smooth with an emery stick or wheel, they are to be 
tempered ; this is a delicate process, requiring much 
experience and care. The point should be warmed in 
a spirit-lamp, and then covered with soap, to prevent 
oxidation and scaling. The instrument is then brought 
to a full red heat with a spirit-lamp, blow-pipe, and 
charcoal, and suddenly plunged into a cake of soap 
or cold water, when it will present a silvery white- 
ness ; the steel in this condition is extremely hard and 
friable. It should then be polished with an emery- 
stick or oil-stone, and drawn down to the proper tem- 
per. This tempering is accomplished by placing the 
edge of the instrument on a piece of cold polished steel 
or iron, and its shaft placed near or in the flame of a 
small spirit-lamp, and retaining it there till it changes 
to a deep blue color, graduated down to the point in a 
deep straw or copper hue. The purpose in holding the 
point of the instrument on a piece of cold polished iron 
or steel is, that the heat there may be subject to com- 
plete control. The precise shade will be governed by 
the purpose for which the instrument is to be used ; if 
for a drill, the edge or point should be of a light straw 
color; indeed, some operators prefer to have them 
scarcely changed at the cutting edge, while excavators 



INSTRUMENTS FOR FILLING. 121 

and chisels should be brought to a deep straw or cop- 
per color ; this will be modified, however, by the man- 
ner of working the steel, and its quality. Skilfully 
hammering steel at a low heat, below a red, gives an 
improved texture, and acids much to its quality for a 
fine cutting instrument. Indeed, some assert that those 
instruments that can be forged to nearly their proper 
shape, can be as well, if not better, tempered by the 
hammer as by any other means. 

The instrument is then to be polished by the emery- 
wheel and dressed up with the oil-stone. Of the va- 
rious methods of tempering the foregoing is equal in 
efficiency, and in convenience superior to any other. 



Filling Instruments. 

For introducing and consolidating fillings, a great 
variety of instruments is in use. In every form in 
which gold is employed for filling teeth the pliers are 
required for taking up the pieces and placing them in 
the proper position in the cavity ; in cylinder or block- 
filling they are indispensable. These instruments are 
made of different forms and sizes — of such forms as 
to facilitate access to cavities inconveniently located ; 
of different sizes to accommodate cavities of various 
capacities. For a large majority of cases they require 
a slight curve, about half an inch from the point; for 



122 



INSTRUMENTS FOR FILLING. 



some cases, however, the curve should be a right-angle. 
(Fig. 32.) 

The points of the pliers, when closed, should present 
such a form as to be used, to some extent at least, for 
consolidating the gold. This instrument should be 
about five inches long. 

The forms of condensing instruments may be mul- 
tiplied to an almost indefinite extent. They are all, 

Fig. 32. 




however, but modifications of two or three general 
principles. The particular form of the plugging- 
point will be determined by the form in which the 
gold is used. With non-cohesive gold, small square, 
or round sharp points of various carves are required. 
These points are easily kept in proper condition, and 
in some instances are used for years without change or 
repair. 

A favorite method of filling with non-cohesive gold, 
by many excellent operators, is in the use of cylinders 
or blocks ; for this method instruments especially 



INSTRUMENTS FOR FILLING. 



123 



adapted have been devised, which the following cut 
represents : 



Fig. 3a 




Fig. 84 is square from the curve to the point, and 
is used in the same manner, and for nearly the same 
purpose, as Fig. 33. 



Fig. 34 




For introducing and condensing key-blocks — those 
intended to bind the filling in place — Fig. 35 is the 
proper form : 



Fig. 35. 



124 



INSTRUMENTS FOR FILLING. 



Figs. 36 and 37 are designed for condensing the 
surface of crown fillings, in the superior and inferior 
molars respectively . 



Fig. 36. 




Fig. 37. 




The instruments represented by the following are 
for condensing the surfaces of proximate fillings. 

Fig. 38. 




Fig. 39 represents round right and left condensing 
points to be used in filling proximate cavities. 

Fig. 39. 




INSTRUMENTS FOR FILLING. 



125 



Figs. 40 and 41 are flat, right and left condensing 
points, for same cavities as Fig. 39. 



Fig. 40. 




Fig. 41. 




The following cuts represent a set of filling in- 
struments devised and arranged by Dr. W. G. Reel- 



man. 



They constitute probably the most complete set 
made, for filling with blocks or cylinders for non-co- 
hesive gold. They are made with ebony or ivory 
handles, and are used with hand force only. 

With cohesive gold in any of its forms, the points 
all require to be serrated. There are three or four 
varieties of these, which it will be proper to describe. 
The first is square, and slightly bent about half an 
inch from the end, which is formed into four or six 
definite sharp points with the edge of a thin file. Of 
this variety there should be about five sizes, the largest 



126 



INSTRUMENTS FOE FILLING. 



entering No. 18 of Stubb's gauge, and the smallest No. 
38. The former should have six points, and the other 



Fig. 42. 







# o 




two sizes four. (Fig. 43.) The cuts upon these are 
made directly across the end. In another variety the 

Fig. 43. 




■3 © 



INSTRUMENTS FOR FILLING. 



127 



end is rounded, and the file placed upon it at an acute 
angle with the side of the instrument, and the cuts, 
three in number, are made to the centre of the point, 



Fig. 44. 




which thus becomes triangular, or three-pointed, from 
a common centre. (Fig. 45.) Four or five sizes of 
these may be employed, ranging from 18 to 26, Stubb's 

Fig. 45. 




gauge. A thin double point, from 26 to 28, is in 
many cases very valuable. Instruments with a con- 
densing surface on the side, instead of the end, will 



Fig. 46. 




frequently be required for filling lateral cavities ; 
these may be denominated lateral pluggers. (Fig. 
46.) This condensing surface should also be serrated, 



128 



INSTRUMENTS FOR FILLING. 



as already described. An instrument square at trie 
point, ranging from 18 to 22, and cut upon the end 
by passing it along the cuts of a file both ways, thus 
making a large number of small serrations at right 
angles across the point, is valuable for consolidating 
the surface of a plug. (Fig. 47.) Operating super- 
ficially on the principle of the more deeply serrated 

Fig. 47. 




instruments, it yet leaves the surface free from deep 
pits or indentations, and still so impressed that it will 
receive and retain more gold, if necessary, as it would 
not do if the end of the instrument was perfectly 
smooth. A smooth-pointed instrument or burnisher 
may be applied after all the gold has been added. 

Fig. 48. 




Fig. 48 is an instrument with file-cut sides. It is 
valuable for dressing down proximate fillings to a uni- 
form surface. There may be two, one with the sides 



INSTRUMENTS FOR FILLING. 



129 




parallel with the shaft, and one with its sides trans- 
verse to the shaft; it terminates in a sharp edge. 

In considering this subject thus far, the aim has 
been to present the principles that should be embraced 
by instruments for properly filling the various classes 
of cavities that are presented. 

Within the last ten years great changes and im- 
provements have been made in this class of instru- 
ments, especially with reference to classifying and sys- 
tematizing them. 

It will be seen by the accompanying illustrations 
that considerable attention has been given in this di- 
rection. Fig. 49 presents Dr. W. H. Atkinson's 
" Omega " pluggers. 

Those who have become familiar with these instru- 
ments prize them very highly. 

Dr. F. Abbott's set of pluggers are also regarded 
highly by many. (Shown in Fig. 50.) 



130 

Fig. 50 a. 
I \ 



o a 



INSTRUMENTS FOR FILLING. 
Fig. 50 b. 



\\\ 



*\ 






n 



i 



Fig. 51 



This cut (Fig. 51) represents Dr. Lewis Jack's 
"Matrix" pluggers. They are designed for and are 
well adapted to operations in which the matrix is re- 
quired. 



Fig. 51 b. 




Fig. 52 represents Dr. R. W. Varney's set of 
pluggers. These were among the first regularly 
arranged sets of pluggers, and, in some respects, 
superior to any that preceded them, and became very 
popular. 

Fig. 53 represents Dr. C. E. Butler's set of pluggers, 



52 a. 



INSTRUMENTS FOR FILLING. 
Fig. 52 b. 

t e ftfH 



131 

Fig. 53 a. 

7° 1 ' 



different in some respects from all the others, but ex- 
cellent nevertheless, and better adapted for some cases. 



Fig. 53 b. 



siii 1 




11 ^ 




Fig. 54 shows in many important respects the most 
perfect set of 'plugging instruments ever made. They 
are the result of long and patient investigation ; they 
will be at once recognized as the work of Dr. Cory don 
Palmer. 

The following cut illustrates them as well as the 
engraver's art can do it. 



132 



INSTRUMENTS FOR FILLING. 
Fig. 54. 




20 21 22 23 24- 25 26 27 28 29 30 



INSTRUMENTS FOR FILLING. 133 

A minute description of each, with the directions for 
its use, is given in section B, in the Appendix. 

In many cases, a valuable instrument for consoli- 
dating is the plugging-forceps, the general form of 
which, except the beaks, is that of the ordinary straight 
extracting forceps. The beaks are formed into sockets 
for the reception of the plugging-points, one of which 
is of the common construction, but the other has a 
broad flat surface to rest against the tooth. (Fig. 55.) 
This instrument is applicable only in certain cases, 
principally in filling proximate cavities. Its main ad- 

Fig. 55. 



vantage consists in its capability of applying a strong 
pressure upon the filling without affecting the socket. 
Manipulation with it is less rapid and definite than 
with the ordinary condensing instruments ; and with 
it, too, there is much danger of fracturing friable 
teeth. 

There has been, within the last few years, very 
great improvement made in the serrated plugging 
instruments — those employed for working cohesive 
foil. It consists in delicacy and perfection of form, 
a large addition to the variety, and a good systematic 
arrangement 



134 



INSTRUMENTS FOR FILLING. 



These instruments are now manufactured and put 
up in sets, embracing every requisite form, numbering 
from forty to sixty ; this includes .surface condensers 
and burnishers. 

The profession is largely indebted to the efforts 
of Drs. Palmer, Atkinson, and Abbott, of New York, 
for the perfection obtained in the production of these 
instruments. 

The File. 

Of this valuable and indispensable instrument there 
is a variety of forms used by the dentist. The thin 

Fig. 56. 




files (Fig. 56) are chiefly applicable to the anterior ; 
the thick, heavy, knife-shaped (Fig. 57) to the pos- 
terior teeth. The latter, to facilitate their approach 
to the points operated upon, have various curves, some 
single, others double, the double being preferable, since 
they bring the handle of the instrument on a line 
with its cutting edge. The cuts upon this instrument, 
too, are quite various; in size, ranging from very 
coarse to very fine, and in obliquity from a line almost 



THE FILE. 



135 



at right angles across it to one at an angle of forty-five 
degrees. These cuts, too, are either single or double, 
the double being those made across one another. The 
single, however, are preferable for all operations on 



Fig. 57. 



— — 1 1 1 I — ) 




the teeth, and the more oblique are to be recommended, 
since they cause less of that jarring unpleasant sensa- 
tion to the patient. 



Fig. 58. 




There are in use various forms of file-carriers, two 
of which are represented in Figs. 58 and 59. Fig. 
59, denominated " Redman's file-carrier, " is an excel- 
lent instrument, one principal advantage of which 
consists in the facility with which it may be changed 
from the one side to the other. Files are made 
adapted to the instrument, the chief advantage of 
which is that it retains the file much more firmly 



136 



INSTRUMENTS FOR FILLING. 



than it can be held in the fingers. These carriers are 
made with a variety of curves to accommodate dif- 

Fig. 59. 




ferent positions. There is also a great variety of 
small file-point instruments for dressing down fill- 

Fig. 60. 




ings, the more important of which are represented in 
Fig. (i(). 



THE FILE. 137 

The Use of the File. — When a separation of the 
teeth is requisite, preparatory to filling, it is fre- 
quently accomplished, either in whole or in part, 
with the file, though now far less frequently than for- 
merly. Principally, in such a case, its use is re- 
stricted to finishing and smoothing, after the greater 
portion of the work has been done with the heavy 
cutting instrument, or, in dressing off the thin at- 
tenuated edges. The file is valuable for removing 
superficial decay, being called into frequent requisi- 
tion in caries of this kind. It is employed to dress 
off roots preparatory to the insertion of pivot teeth, 
for which purpose it is required to be of a round 
or half-round form. It is used for dressing off sharp 
portions or edges of the teeth that may be injurious 
to the soft parts, and, in some cases, for dressing 
down a tooth that is elongated. In finishing many 
fillings it is almost indispensable. It was formerly 
used to some extent in the treatment of irregularity, 
but for this purpose it has been abandoned. 

Mode of Using the File. — The patient should be con- 
veniently seated, with the head on a firm support, 
and under the control of the operator, who should 
occupy a position at the right of the patient, in most 
cases, so disposing the head of the latter as to give 
free access to that point which is to be operated 
upon. In manipulating with the file considerable 
skill and delicacy are requisite. It should not be 



138 INSTRUMENTS FOE FILLING. 

held with a stiff, unyielding grasp, so as to catch and 
jar, but should be applied with a gentle pressure, 
and drawn across the tooth with a free and flexible 
motion. It should be frequently moistened, and not 
allowed to clog with the filings, being kept free of 
these by repeated applications of the brush. A sharp, 
new file, with a quick, light movement, will cut far 
more rapidly, and less unpleasantly to the patient, 
than one that is dull or clogged applied w r ith a heavy 
pressure. If the tooth bone is sensitive, the file 
should be moistened in warm water. For cleansing 
files, when clogged with dentine, the wire brush in 
common use is quite efficient. Every operator should 
have one at hand. The form of a file may be changed 
by drawing the temper, bending it as desired, and 
then retempering it. It is better, however, to have 
them made of the proper form at first, 

The teeth, while being filed, should be supported 
by the fingers, or by an instrument for the purpose; 
or a cork or piece of soft wood may be inserted be- 
tween the tooth being filed and the teeth of the op- 
posing jaw, and the pressure thus used as a support. 
The tooth being sustained in this manner, there is 
less jarring experienced by the patient, and less lia- 
bility to produce irritation of the periosteum. When 
filing the anterior teeth it is generally better to hold 
the file in the fingers. For filing the incisors and 
cuspids a thin, bevel-edged file is to be preferred. 



THE FILE. 139 

In dressing a tooth with a file, the last that is used 
should be a fine one, after the application of which 
the surface operated upon should be made as smooth 
as possible with a stone and burnisher, or with a buff 
and rotten-stone. 

In separating teeth with a file, where but one is 
decayed, care should be taken not to cut the sound 
one. For this purpose it will usually be necessary 
to have a safe-sided file, one side smooth to present to 
the sound tooth; and, even then, the cutting edge 
should be somewhat bevelled from the safe side, that 
the sharp angle of that edge may not rasp the sound 
tooth; in no case of this kind should a square-edged 
file be used. In cases in which it is necessary to 
file teeth that are somewhat loose in the sockets, and 
whose periosteum is in a state of irritation, to build 
up a wall of plaster of Paris round them, permitting 
it to harden, will very much facilitate the operation. 
Perhaps a preferable method, in some respects, for 
accomplishing the same object, is to mould softened 
gutta-percha to the tooth and the parts about it; after 
it has become hard, hold it firmly in place while the 
filing is accomplished. Or, binding three or four 
teeth, including the loose one, with fine silver wire, 
the loose tooth will be held firmlv. Either of these 
methods will be found valuable in cases where it is 
necessary to dress off a considerable portion from the 



140 INSTRUMENTS FOR FILLING. 

end of one or more of the inferior front teeth. There 
are some teeth upon which the use of the file is 
hardly admissible; as, for instance, those which are 
highly predisposed to inflammation and sensitiveness 
of the dentine. The teeth of young persons, being 
often of this character, should be filed with great 
caution, but, in general, those of adults may be 
filed if properly done, with more freedom. The file 
should not be used upon the teeth when the peri- 
osteum, the gums, or the mucous membrane is dis- 
eased, or strongly predisposed to such a condition. 
It should never be used for the correction of irregu- 
larity of the teeth, especially when they are sound ; 
nor should it be employed to separate sound teeth 
to introduce clasps. 

Filing the teeth is an operation against which 
there has been and still is much prejudice, though 
without sufficient cause. Whatever injury results 
from this operation is from the imperfect manner in 
which it is performed, and from subsequent neglect 
of the tooth which has been subjected to it. A tooth 
skilfully treated with this instrument, and properly 
cared for afterward, will not be more liable to decay 
at the point operated upon than at any other where 
the dentine may be exposed. 

Since the introduction of the disks to be used with 
the engine, and especially the diamond disks, the de- 



THE FILE. 141 

mand for the file for separating and dressing the 
teeth has become very greatly diminished, and, in 
the practice of some, almost wholly superseded. It 
is well, however, that the student should learn the 
use of the file. 



CHAPTER Y. 



SEPARATION OF THE TEETH. 



In most cases of proximate decay, the teeth, before 
the operation of filling can be performed, must be 
separated; though cases are not unfrequent where 
the space between them is sufficient to admit of free 
manipulation without this preliminary. An imper- 
fect accomplishment of this first step in the process 
of filling is a prolific source of the many failures, in 
proximate cavities, to attain to efficient and durable 
results ; for unless this step be thoroughly performed, 
so as to make room for the free introduction and 
use of the various instruments requisite, no part of 
the work can be complete.. Though the most com- 
mon object for which teeth are separated is to ob- 
tain space for free manipulation with the instru- 
ments in filling, yet there are various other objects 
for which they have been separated, but many of 
which are now better accomplished by other means. 
It is sometimes necessary to cut away more than 
would otherwise be requisite, in order to remove thin, 
friable edges of the cavity, so as to obtain sufficiently 
firm borders. Teeth are in some instances separated 
for the introduction of clasps — a practice always to 



SEPARATION OF THE TEETH. 143 

be deprecated, since it usually proves injurious. 
Though the practice was once very common, yet 
most if not all the best operators have now, with 
good reason, abandoned it altogether. At one time, 
too, it was a general practice to separate the teeth 
with the file to relieve a crowded condition ; but this, 
also, has been superseded by better processes. 

There are two methods of separating the. teeth: 
the one, to cut away a portion ; the other, to force 
apart by pressure, acting upon one or more teeth, as 
the circumstances admit. Formerly, all separations 
were effected by the file, and this of very crude 
form and cut, b} T which instrument, especially in 
unfavorable cases, much injury has been done. 
Though the file is a valuable instrument, yet, for re- 
moval of any considerable portion of dentine, it is 
not to be recommended. Its action upon sensitive 
dentine is exceedingly painful, besides being tedious 
and wearisome to the patient and operator; it is also 
liable to irritate the periosteum, and to increase in- 
flammation. When a separation is to be made that 
requires the removal of a considerable portion of the 
tooth, the chisel, or cutting instruments, illustrated 
on pages 100 and 101, are to be preferred. These, 
if of the proper form and temper, and in good condi- 
tion, are very efficient for the purpose, performing 
the work far more rapidly than the file, and far less 
unpleasantly to the patient. They effect the remo- 



144 SEPAKATIOX OF THE TEETH. 

val of sensitive dentine with but little or no pain, 
and without liability to increase the inflammation, 
or to produce irritation or disease of the periosteum. 
The force of these instruments is sustained by the 
entire attachment of the tooth, their pressure being 
applied almost in a line with its axis. Besides, by 
their use, the contiguous teeth are not liable to in- 
jury, as by the use of the file they often are. 

The manipulation with these instruments is very 
simple. For separating front teeth, the instrument 
is firmly grasped in the hand, the thumb placed on 
the points of the teeth, and the edge applied at the 
point or crown surface of the tooth from which the 
portion is to be removed, and pressed gradually to- 
ward the gums, but not thrust into the interval as 
a wedge before it has freely cut its way. In this 
manner,, as much of the dentine as it is desirable to 
remove is cut off in a few moments. This class of 
instruments is invaluable for forming the V-shaped 
spaces between the bicuspids and the molars that 
have been popular with many operators, but are 
pointedly condemned by others. It requires a pro- 
longed use of the file to make these separations 
properly ; and hence the practice of attempting to fill 
proximate cavities without any separation at all, by 
operating through a small opening at the crown an- 
gle of the tooth, or a small hole drilled through its 
outer or inner portion. With the cutting instru- 



SEPAKATION OF THE TEETH. 



145 



ments, points upon the teeth that the file cannot 
touch are approached and operated upon with facility. 
Another method of effecting the same kind of sepa- 
ration is, by the use of the corundum disks, used 
with the dental engine. 

The profession is indebted to Dr. Robert Arthur 
for devising and rendering practicable this very valu- 
able appliance. 

These disks, as seen in the following illustration, 
are made of various forms, suitable to meet all cases. 

Fig. 61. 




For using the disks, carriers have been devised 
and made. These should possess three qualities, viz., 
ready adjustment to the hand-piece of the engine; 
facility of attachment and release of the disk; and 
the easy change of the disk to any desired angle with 
the shaft containing it. That invented by Dr. George 
H. Cushing possesses these qualities in a marked 
degree, and is very effective. 

The dotted lines in the figure show the angular 
range of movement of the disk upon its shaft. 

For convenience and safety in using the disk, a 

10 



146 



SEPARATION OF THE TEETH. 



shield or covering is adapted to it that effectually 
protects all parts except that operated upon. 



Fig. 62. 




By means of this instrument, separations of little 
more than a mere opening to the largest Y-shaped 
space can be readily made, and it is claimed with 



Fig. 63. 




equal if not greater ease to the patient than by any 
other method. 

Skill and experience are required for their facile 
use. 

The use of the disk has largely superseded that of 
the file for separating teeth. 

But the method of separation by pressure is in 
many cases to be preferred, especially in the case of 
anterior teeth, whose natural form it is important to 
preserve. 

Till within a comparatively recent period, it has 
been the general practice to separate by gradual 



SEPARATION OF THE TEETH. 147 

pressure ; and it is even yet the favorite method with 
some operators. Bat in almost all cases where sep- 
aration is to be made by pressure, it can be done at 
once quite as well, if not better, than to prolong the 
process through several days ; there is economy of 
time, and the patient experiences less pain, and there 
is less liability of doing injury to the teeth or the 
parts about them. 

The anterior teeth, or those of single roots, yield 
very readily to a strong separating force, applied in 
the form of a wedge, notwithstanding the teeth may 
all be in contact with each other ; though in some 
cases the teeth are so firmly set, and the parts about 
them so dense and unyielding, that it is with great 
difficulty they can be moved, without too much vio- 
lence to the parts. It is not generally practicable to 
attempt to separate the molar teeth by pressure. 

The method of effecting immediate separation is 
very simple ; it consists in forcing a wedge of some 
fine-grained wood of medium resistance — orange or 
box wood — between the teeth to be separated, either 
by pressure with the hand, or by the blows of a mallet. 
The wedge should be driven in at the necks of the 
teeth ; before this, however, a shield- wedge should 
be put between the necks of the teeth against the 
septum of gum ; it should be of such form as to re- 
tain its position while the chief wedge is being driven 
in; and when they are very firm,, an assisting wedge 



148 SEPARATION OF THE TEETH. 

may be used, inserted between the points of the teeth, 
and receiving strokes alternately with the other. The 
assisting wedge should be of very dense wood, and 
driven in with great care, for its leverage upon the 
teeth is very great. When the required space is ob- 
tained, the wedge at the necks of the teeth should be 
driven tightly in, and the other withdrawn. If all 
the teeth in the vicinity of those to be separated stand 
in contact, the resistance to separation, whether by 
immediate or gradual effort, will be greater. 

For the introduction of the wedge a dental wedge- 
forceps has been devised ; for forcing wedges between 
the teeth this is preferable to the mallet, as the 
unpleasant blows of the latter are avoided; the wedge 
is introduced by gradual pressure, the teeth are sup- 
ported by the opposing jaw of the forceps ; and again 
the wedge can be as easily introduced from the inside 
as the outside of the arch, which in many cases is a 
great advantage. 

Two forms of appliances, denominated separators, 
invented by Dr. Jarvis, are very valuable aids in the 
separation of the teeth. The one is for separating 
the anterior and the other the molar teeth. The 
former is described as consisting of two steel wedges 
approaching and passing each other; being thus 
drawn together by a thumb-screw, making gradual 
and prompt separation where it is applied. 

Its operation is much more acceptable to the patient 



SEPARATION ( »F THE TEETH, 



149 



Fig. 64. 




150 SEPARATION OF THE TEETH. 

than that of the ordinary wedge driven with the 
mallet. It will be found useful in making room for 
passing rubber-dam between crowded teeth. It may 
also be used to advantage in connection with the 
wedges. 




That for the molars consists of a properly formed 
piece of steel, bent upon itself, with the ends formed 
to fit the outer and inner portions of the proximate 
surfaces of two adjoining crowns. 

These jaws are forced apart by the action of a 
screw, which passes through one and against the 
other. 

This form is applicable to all the bicuspids and 
molars. It does not touch the gum or injure the 
teeth, neither does it cause much pain. 

The appliance may remain on the teeth in some 
cases while an operation is being performed ; other- 
wise a wooden wedge should be inserted between the 
teeth. It is represented by the following figure. 

The rapidity with which the operation may pro- 
ceed, and the extent to which it may be carried, will 
be determined by the tolerance of the parts to the 
movement, which should not be greater than the 
elasticity of the tissues will permit; not the slightest 



SEPARATION OF THE TEETH. 151 

laceration or rupture should be made ; again, great 
care should be observed, lest strangulation of the 
vessels that enter the roots be effected ; this would be 

Fig. 66. 



far more liable to occur in' the teeth of young persons, 
or before maturity. There is in adults, however, a 
great diversity in their susceptibility to injurious 
influences. 

Many operators still prefer gradual separation by 
pressure. In order to secure the most successful 
results the condition of the parts should be strictly 
observed. The gums, periosteum, etc., should be in 
a healthy condition, for much injury may be done 
by attempting to separate teeth by pressure when the 
contiguous parts are in an irritable state. In per- 
sons of a neuralgic diathesis, in those whose vital 
energy is weak, and particularly in those whose con- 
stitutional tendency is inflammatory, this operation 
is scarcelv admissible. If, in such cases, it is at- 
tempted at all, it should be proceeded with very care- 
fully and gradually, and should be preceded by con- 
stitutional treatment. There are many cases in which 



152 SEPARATION OF THE TEETH. 

it is best to make the separation parti} 7 by pressure, 
and then to complete it by dressing off the thin fria- 
ble edges of the cavity with the cutting instrument 
or file. Whether the process is to be wholly or only 
partly accomplished by pressure should be determined 
beforehand. 

Various materials have been employed for sepa- 
rating the teeth by gradual pressure, the chief of 
which are cotton, wood, india-rubber and ligatures. 
The condition and character of the parts to be ope- 
rated upon will usually indicate the material best 
adapted in any given instance. In a good constitu- 
tion, with the teeth firmly set and the contiguous 
parts healthy, wood or india-rubber may be applied, 
but in cases of an opposite character, a more yield- 
ing and tractable material is indicated. The degree 
of pressure to be applied and continued will be de- 
termined by the susceptibility of the parts to irrita- 
tion. Soreness usually occurs in a few hours after 
the introduction of the material. The pressure should 
be gradual and constant, slight at first, and increased 
in force as the patient will bear, the increase being 
made every day, and continued till ample space is 
obtained. The time necessary for the completion of 
this process is from ten to twelve days; only one 
separation should be made at a time. The teeth 
should be retained apart till the soreness has abated, 
before the operation. If not thus retained too long 



SEPARATION OF THE TEETH. 153 

they will steadily return to their former position. It 
is by some supposed that separation by pressure is ad- 
missible only in the case of the young, or those under 
thirty years of age. It is true that they are the 
most susceptible, but the operation is, under favora- 
ble circumstances, proper at any age. 



CHAPTER VI. 



FILLING TEETH. 



The operation of filling teeth is an interesting and 
important one, requiring for its successful accomplish- 
ment peculiar talent and large experience. It is the 
only means as yet ascertained of completely effect- 
ing the object for which it is employed, namely, ar- 
rest of decay and preservation of the organs. Thera- 
peutic agents avail but little here, so low is the or- 
ganization and so feeble the vital power. Nature, so 
efficient in more highly-organized structures, does 
comparatively little in disease of the teeth toward 
arrest or restoration. Yet, on the other hand, these 
organs are less liable to decomposition by the action 
of foreign substances ; indeed, well-organized enamel 
is almost invulnerable to any agents to which it is 
ordinarily exposed. The dentine, however, is more 
easily acted upon, and, when there is defect in the 
enamel, is very liable to injury. 

Scarcely an individual in our country arrives at 
mature age with a perfect set of teeth ; indeed, nine- 
tenths of our people have decayed teeth at an early 
period of life. Hence, for beautifying, preserving, 
and supplying these organs, art is in constant requi- 



EXAMINATION. 155 

sition, and in these respects great achievements have 
been made. In the operation of filling the teeth, es- 
pecially, the achievements are conspicuous ; and here 
is scope for the highest skill. Every successive step 
in the process of filling a tooth demands a complete 
and conscientious application of the most efficient 
and best adapted modes and appliances of the art. In 
the following remarks it is proposed to analyze this 
whole process, examining, in their order, the various 
steps necessary to be taken, and endeavoring to in- 
culcate the true methods of accomplishing them. 

Examination. 

When a case is presented there should first be a 
thorough examination, since by this all the subse- 
quent work will be modified. For this purpose the 
proper exploring instruments should be at hand, 
which should consist of a sufficient number and va- 
riety of fine sharp-pointed instruments, so formed and 
curved as to be readily brought into contact with 
every point of surface of the crown of every tooth, 
and indicate any defect that may exist. 

The accompanying cut represents the common and 
perhaps the best forms of this class of instruments. 

In addition to these, mirrors, reflectors, and mag- 
nifiers, when properly adjusted and skilfully used, 
are very valuable. 



156 



FILLING TEETH. 



There should be two or three sizes of mirrors, ad- 
justable to any angle requisite to reach every point 
in the mouth efficiently. 

Reflectors are desirable for throwing light upon ob- 
scure or dark points. 

Fig. 67. 

/ f I 




Magnifiers are important in examination of the 
teeth, to bring to view defective points that would 
escape detection by the unassisted eye. Every op- 
erator ought to have at hand at least three grades of 




these. Mirrors and magnifiers are combined to some 
extent, but sufficient amplification and definition can- 
not always be obtained in this way for all cases. The 
common mouth-mirror is shown by Fig. 68. 



EXAMINATION 



157 



Mirrors and reflectors are made adjustable upon 
the finger of the operator, as in 



Fig. 69. 





Reflectors adjustable on the rubber-dam clamps 
serve a valuable purpose, and should always be at 
hand. Shown in 



Fki. 70. 





They are also attached to the rubber-dam clamps, 
which makes, for many cases, a very convenient ar- 
rangement. 

Fig. 71 is a magnifier, to be used on the finger of 
the operator. The chief use of the magnifier, how- 
ever, is for examination rather than for operating. 

The points to be noted in the examination are as 
follows : 



158 FILLING TEETH. 

The temperament ; the present health ; the consti- 
tutional tendencies : the secretions, — the saliva and 
mucus ; the mucous membrane and the gums ; the 
constitution and condition of the teeth ; the num- 
ber of them remaining in the mouth ; the number 
affected; the extent and nature of the decay, and 
the character of the agents producing it. By the 
examination we ascertain how to proceed in the op- 

Fig. 71. 




eration ; if much or but little labor is required'; 
whether the operation will be a simple or a difficult 
one; and if difficult what circumstances render it 
so ; and, besides, some conclusion is arrived at in re- 
gard to the precise means to be employed for obtain- 
ing the desired result, as well as the permanency of 

that result. 

Opening. 

The next step is to open the cavity of decay, so 
that it may be approached and operated upon at all 



OPENING. 159 

points. The particular manner of performing this is 
determined by the extent of the decay, and its posi- 
tion upon the tooth. - In all cases the opening should 
be such as to give free access to all parts of the 
cavity, for effectually removing the decayed portion, 
for perfectly forming the cavity, and for introducing, 
thoroughly consolidating and finishing the filling. In 
central crown cavities of the molars and bicuspids, 
the projecting or pendent portions of enamel should 
be cut away. There are cases, however, where such 
portions are firm and not liable to be broken, and 
where they can be well sustained by filling under, in 
which it is admissible to leave some projection. This 
is true of only those teeth which are of good, firm 
texture. There are two objections to these abrupt 
projections of enamel :. it is very difficult and in 
many cases impossible, to fill perfectly beneath such 
portions \, and again, they are liable to be broken 
down during mastication. 

For opening up these cavities, in many cases the 
bur drill alone will be quite sufficient ; those of dif- 
ferent sizes being employed, to open up the orifice 
gradually, so that too much violence may not be done 
to the teeth. In all very small cavities, the bur is 
all that is required, except in decayed fissures, and 
for these the fissure bur is almost indispensable. 

In cases w) ere the decay is more extensive, and 
the cavity larger, the chisel or heavy cutting instru- 



160 



FILLING TEETH. 



ment, in connection with the drill, will be found very 
useful. Fig. 72 represents valuable forms of these 
instruments. 

Fig. 72. 




Fig. 8, page 101, represents instruments for this 
purpose, of various forms and sizes ; they may be 
used either with hand force or the mallet. In cases 
where much cutting is required, the latter method is 
preferable, being more rapid in execution, and less 
objectional to the patient. 

The fine file or bur should always follow the use 
of the chisels, to give a smooth and even surface to 
the part upon which the cutting has been made. 

Removal of Decay. 



After the cavity is opened, the next step in order 
is the removal of the decayed dentine. As a general 
rule, this should be entirely removed. There is, 
however, some variety of opinion upon this subject. 
This difference of opinion is in regard to cases 



REMOVAL OF DECAY. 161 

where an entire or a partial decomposition of the 
dentine has taken place quite to the pulp, where, by 
its removal, the pulp would be exposed. It is main- 
tained by, some that decayed dentine affords a better 
protection to the pulp than any artificial covering ; 
and hence it is better to let it remain, since its adap- 
tation is more complete ; and it is not in every sense 
a foreign substance. 

On the other hand, it is contended that the de- 
cayed dentine, being in an abnormal condition, will 
irritate, and in many cases ultimately destroy, the 
pulp. And again, that there is danger of making 
undue pressure upon the pulp, in filling on such 
softened portion. 

In many cases it is maintained that partially de- 
composed dentine will become dense again, if pro- 
tected from the influence of foreign agents that de- 
compose it. This sometimes would seem to be 
true. For in some cases where fillings have been 
introduced into cavities, at the bottom of which a 
portion of softened dentine covered the pulp, on re- 
moving them in from one to five years afterward, 
all parts of the cavity were found to be equally and 
normally dense. This, perhaps, would occur only 
in good constitutions, and under favorable circum- 
stances ; but with such constitutions and circum- 
stances, where the softening is not too extensive, 
and the decomposition but partial, it may be per- 
il 



162 FILLING TEETH. 

mitted to remain, with a strong liability of a favor- 
able result. This would certainly be better than to 
cut it all away, and expose and perhaps wound the 
pulp, and then endeavor to cover it with some 
wholly foreign material that would not be perfectly 
adapted to it, that would press a little too hard at 
one point and not touch at another, and that would 
be quite as liable to be pressed down on the pulp as 
the softened dentine. 

In this discussion much depends upon the point, 
whether partially decomposed dentine can retain its 
vitality. This it is not now proposed to consider. 
There are some particulars in regard to the removal 
of decay, however, about which there is no diversity 
of opinion : first, that all decomposed dentine should 
be removed from all parts of the cavity, where the 
pulp would not be exposed or injured thereby; and 
that in all cases it should be entirely removed from 
the lateral walls of the cavity, and especially from 
the vicinity of the orifice. Even discolored dentine 
should be removed from this part, unless weakening 
of the borders or walls would thereby be occasioned. 

Dentine often becomes changed in color when 
there is no apparent decomposition ; such portion is 
usually, though not always, without vitality. It is 
not important to remove such changed portion ex- 
cept for the appearance of the tooth; it will produce 
no change upon the living or normal part beyond 



REMOVAL OF DECAY. 163 

it; and it is better material to be in contact with 
the living part than any metal of which a filling 
may be made. 

Decayed dentine is readily removed with the ex- 
cavators. In any given case, such instrument should 
be selected as would be best adapted for the pur- 
pose, as well in regard to size and the form of its 
edge, as to the curvature, or inclination of its shaft. 
The edge of the instrument should come upon the 
walls of the cavity at such an angle as to accomplish 
the work most efficiently. It should be very sharp, 
and pressed firmly to the bottom of the decay at 
one side, so as to remove the principal part at one 
cut. So far as possible, the direction of the cutting 
should always be from the nearest point of pulp ex- 
posure, toward the orifice of the cavity. With the 
proper instrument, and that in the right condition, 
all the decay should be removed from any cavity 
by a few r firm, steady strokes. By this method less 
pain is caused the patient, and the work of the oper- 
ator is facilitated. It is intolerable to think of being 
subjected to an awkward, clumsy hand, with a dull, 
ill-shaped excavator, scratching upon the surface of 
a decayed tooth, for a length of time apparently to 
the patient interminable. 



164 FILLING TEETH. 

Forming Cayities. 

The next step in the operation is the formation of 
the cavity. By this the cavity is so formed that it 
will well receive and retain the filling when properly 
introduced. In very few cases is the cavity of 
proper form when the decay is removed \ but in al- 
most every instance more or less of the solid dentine 
must be removed to secure a proper form to the cav- 
ity. Much time, patience and labor are required of 
the operator for the proper accomplishment of this 
part of the work, and much endurance on the part 
of the patient. In this part of the work several 
particulars require consideration. The great object, 
however, is to give to the cavity such a form as will 
secure the most perfect adaptation of the filling to 
every point, and its permanent retention in place. 
The cutting for the formation of the cavity should 
be accomplished with the least possible loss of healthy 
dentine; this is a point upon which good judgment 
should be exercised. The strength of the walls of 
the cavity, and the ability of the parts to withstand 
the pressure, both in the introduction and consolida- 
tion of the filling and in the act of mastication, 
should be well noted. It may be regarded as a rule 
from which there should scarcely ever be a depar- 
ture, that the enamel should never be encroached 
upon, through the dentine, in excavating to give 



FORMING CAVITIES. 1G5 

form to a cavity. When there is but a lining of den- 
tine at any given point on enamel, after the o>cay 
is removed, it should remain for the preservation 
of the enamel ; it should not be cut through either 
by pits or by grooves, much less should any consid- 
erable portion be removed. 

There are cases occasionally in which the dentine 
is wholly decayed, and its removal lays bare the 
enamel : when such a case occurs, the enamel should 
be retained in as perfect a condition as possible, and 
no attempt made to form pits or grooves in it. The 
reason for this is found in the friability of the 
enamel. 

. It may be regarded as an axiom, that where it is 
necessary to cut the healthy dentine to give proper 
form to the cavity, it should be clone at that part of 
the cavity where the tooth will suffer least from the 
loss. The precise point and amount of cutting will 
be determined by the form and size of the cavity, 
and the amount of solid dentine remaining after the 
decay is removed. 

In small cavities, where there is sufficient material 
to work upon, the object is to give the cavity a reg- 
ular form, and make the retaining-points where it is 
most convenient and efficient. 

In large cavities, where one side of the tooth is 
weak, places must be selected for making the re- 
taining-points that will least affect the weak point. 



166 FILLING TEETH. 

Frequently, in proximate decay of the anterior teeth, 
the labial and palatal walls are friable, and would 
be easily broken ; much cutting upon such walls 
would not be admissible. Again, the decay often 
extends towards the point of the tooth, down to the 
union of the labial and palatal plates of enamel ; in 
cases of this kind, all that can be done at this point 
is to remove the decay ; and fracture will sometimes 
occur even in accomplishing this. 

In some instances, as in the crown cavities of the 
molars, the cavity will be nearly or quite of proper 
form when it is perfectly open, and the decay all re- 
moved. This is the case when the decay is confined 
to a simple perforation of the dentine, without any 
considerable lateral extensions. In proximate cav- 
ities there is always more or less excavation of the 
solid dentine required, to give the cavity proper form. 

There is no definite rule for the formation of cav- 
ities, that will be applicable in all cases. The form 
will be modified by the tooth, the position of the 
decay upon it, the extent and ramifications of the 
decay, and the manner in which it is to be filled. It 
is given, by some, as a rule, that the depth of a cavity 
should be equal to its least diameter. This is a direc- 
tion, however, of no general application, for many 
cavities will be much deeper than the greatest diam- 
eter, as in crown cavities of the molars ; and the re- 
verse will often occur, as in labial cavities of the supe- 



FORMING CAVITIES. 167 

rior incisors, and in proximate cavities of the molars, 
in which it would be impossible to make anything 
like an approach to this rule, without exposing the 
pulp, and even cutting through its chamber. 

A general direction, and one that we thinks good, 
and applicable in many cases, especially in crown 
cavities of the molars, and in almost any of the 
deep perforations by decay, is to make the walls of 
the cavity as nearly as practicable parallel with one 
another. This rule is applicable in almost all small 
cavities. 

In medium or large-sized cavities, it is admissible 
to leave them slightly larger at the bottom than at 
the orifice, if circumstances require ; a large cavity 
of this form can be perfectly filled, when a small 
one could not, from the fact that in the former there 
is more room to operate in introducing, adapting and 
consolidating the filling. 

Cavities that are larger within than at the orifice, 
should have their walls perfectly plain, smooth sur- 
faces, free from transverse grooves or depressions, so 
that the gold may be accurately adapted to them. 

It is sometimes necessary to leave a cavity slightly 
larger at the orifice than at the bottom. This may 
be done by a diverging inclination of the wall of one 
or more sides of the cavity. When there is an in- 
ward inclination of the wall at one side of the cavity, 
the general form may be such as to retain a filling 



168 



FILLING IEETH. 



perfectly, for there may be two opposite sides parallel, 
or even divergent ; in that case, the axis of the cav- 
ity will not be in the direction of the centre of the 
crown. 

Two opposite sides may converge and the others 
diverge, and a filling be retained firmly. When two 
contiguous sides have the same converging inclina- 
tion, making the orifice larger than the interior, if 
the walls are smooth, plain surfaces, a filling will not 
be retained ; but retaining-points may be made by 
forming transverse grooves or pits upon them, and 
by this means the filling be firmly retained. As a 
general rule, it will be necessary, when the orifice is 
larger than the cavity within, to make grooves or 
pits on the wall. For this purpose the diamond- 
point excavator is invaluable. 

If the cavity is large, and the walls near the orifice 
thin, and liable to be broken, the situation of the 
grooves or under-cutting should be farther within the 
cavity than if the walls are firm out to the edge. 
Sometimes it is best to make little pits at the bottom 
of such cavities for retaining-points. In cases where 
it is necessary to make an under-cutting, one or two 
little transverse grooves upon one side will be suffi- 
cient, and in no case on more than two sides, leaving 
the others perfectly plain surfaces. 

In the formation of retaining-points in difficult 
cavities, there is considerable diversity of practice : 



FORMING CAVITIES. 169 

under-cutting and grooving have been very com- 
monly employed. Another method in common use 
is that of drilling little holes or pits into the dentine 
at the most favorable points, these taking different 
directions. This kind of retaining-points is much 
better calculated to answer the purpose, in filling 
with crystal gold, or cohesive foil, than with the or- 
dinary non-cohesive foil after the old methods. When 
these perforations are made at different inclinations, 
and then perfectly filled with cohesive gold of any 
kind, the filling will certainly be retained in place. 
For making these perforations, a small square-edged 
drill is the proper instrument. 

Such retaining-points are seldom or never required 
in crown cavities of the molars; but in proximate 
cavities they are frequently employed with great ad- 
vantage. In forming them care should be exercised, 
lest the pulp-chamber is encroached upon by the in- 
strument. In almost all cases, the proper point for 
forming them is in the cervical wall of the cavity. 

Some operators discard any definite retaining-points, 
grooves or angles, but aim, instead, to give a general 
retaining form to that part of the cavity in which 
the filling is to be commenced, and upon which re- 
liance is to be placed for its retention. The advan- 
tage of definite retaining-points is twofold ; first, to 
facilitate the introduction of the first part of the fill- 



170 



FILLING TEETH. 



ing ; and second 



ts more certain retention after it is 
in position. 

Another particular to which attention should be 
given is the border of the orifice. It should always 
be an object to secure an even, smooth and strong bor- 
der to the orifice of the cavity. It is impossible to 
make a good finish with a rough, uneven border ; 
the filling is also more exposed to injury by mastica- 
tion. The integrity of a smooth, plain surface is 
retained under influences that would break up and 
destroy an uneven one. Some operators polish the 
borders of all cavities, before filling, as perfectly as 
possible, and regard, no reasonable amount of labor 
in this direction as lost. This polishing certainly 
adds to the security of an operation. It is also very 
desirable to have a firm margin ; to obtain this, it is 
often necessary to cut away more than would other- 
wise be desirable. A smooth, firm border should not 
be sacrificed for the form, and especially in the pos- 
terior teeth. It is very objectionable to some persons 
to have the perfect form of the front teeth nrarred or 
changed ; but it should be remembered that even a 
front tooth one third cut away, and so filled as to be 
permanently preserved, is far more valuable than an 
artificial one. 

Another particular that should always be observed, 
is the removal of all acute angles, and especially 
when, they are in the vicinity of the orifice of the 



FORMIXG CAVITIES. 171 

cavity. These are seldom or never found in proxi- 
mate cavities of the molars and bicuspids ; occasion- 
ally they are found in proximate cavities of the cus- 
pids, and frequently in proximate cavities of the in- 
cisors, particularly at that part of the cavity next to 
the cutting edge of the tooth. Such angles are very 
often found also in crown cavities of the molars and 
bicuspids, where there is an extension of the decay 
along one or more of the fissures of the crown. 

It is difficult — almost impossible — to fill perfectly 
a sharp angle, and hence the necessity of obliterating 
such when it occurs. This may be done either with 
a small delicate cutting instrument or with a small 
bur drill. It is an operation requiring great care 
and delicate manipulation, at least so far as the an- 
terior teeth are concerned. When a sharp angle 
occurs in the proximate cavities of the front teeth, 
it is usually near the cutting edge of the tooth, just 
at the union of the labial and palatal plates of en- 
amel. A small chisel-shaped instrument is very 
good for cutting out such angles ; indeed, in fissures 
of crown cavities of molars, where the decay extends 
backward, the straight chisel-shaped instrument is 
just adapted to this purpose; but where there is an 
anterior extension, the instrument should be curved 
to almost a right angle, and forced down by pressure 
of the thumb of the left hand. The small burs and 
fissure drills, represented by Figs ; 20 and 22, used 



172 FILLING TEETH. 

with the dental engine, will meet the requirements 
in such cases with great facility. Some good opera- 
tors recommend a slight reaming at the orifice of all 
cavities, where it can be accomplished. The object 
of this is twofold : to remove the sharp angle at the 
orifice of the cavity, as it is liable to be fractured or 
roughened in putting in the filling; and to give a 
better margin to the filling. In making this bevel, 
the bur, if one be used, should be but little larger than 
the orifice of the cavity. The cutting should be but 
slight — just sufficient to remove the sharp corners ; 
much cutting here would give too thin and yielding 
an edge to the filling. 

Exclusion of Moisture. 

The complete and certain exclusion of saliva, and 
all moisture from a tooth that is to be filled, has 
ever been a great desideratum ; and till within a 
comparatively recent period, was attained with diffi- 
culty. A great many appliances and methods have 
been employed for the accomplishment of this object. 
The usual method was to pack about and around the 
tooth upon which an operation was to be performed 
napkins, bibulous paper, spunk, etc., retained in 
place by holders. These, in most cases, were effect- 
ual but for a short time, and when the flow of saliva 
was abundant, constant vigilance and effort were nee- 



EXCLUSION OF MOISTUEE. 173 

essary to secure the proper exclusion of moisture. 
Quite a variety of instruments and appliances have 
been employed for holding in place these various 
paddings. Some of them were to be held by the 
patient, others were so formed as to clamp the rolls 
or pads firmly in place. 

None of these appliances had reference to check- 
ing the flow of saliva by compression upon the 
mouths of the ducts; this, however,, in due time 
was introduced. Various appliances and adjustments 
were made with this object in view. Pads of cloth, 
bibulous paper, spunk, and disks of pipe-clay, were 
the principal things used for this purpose ; they were 
placed and held firmly on the mouths of the ducts 
by clamps, springs, etc. A good degree of success 
'was in this way attained in some cases, in others it 
is impossible to close all the ducts ; and in almost 
every instance these things stimulate an excessive 
flow of mucus. Filling the mouth in the manner 
just described was always objectionable to the patient, 
and in many instances could not be tolerated. 

In addition to all these things, various pumps were 
devised for removing the saliva from the mouth as it 
accumulated, all of which were more or less objec- 
tionable. 

All these modes and appliances have been super- 
seded by the introduction and use of the rubber dam 
and saliva extractor. For the former of these the 



174 FILLING TEETH. 

profession is indebted to Dr. S. C. Barnum, and for 
the latter to Dr. J. E. Fisk. 

The rubber dam is, by all those who understand 
its use, justly regarded as an invaluable boon. It 
can in any and all cases be applied so as to abso- 
lutely exclude moisture from a tooth or teeth while 
being operated upon. It does not, however, prevent 
the free flow of saliva into the mouth, and in many 
cases this occurs to a very objectionable extent, and 
either the patient must swallow it, — and with the 
rubber dam in place very few can do this,— or it must 
overflow from the mouth, which is very unsightly, 
inconvenient, and annoying, or it must be drawn 
from the mouth. 

About ten years ago Dr. Fisk made available 
the principle of the Gifford injector, devising the 

Fig. 73. 



saliva extractor, a very valuable appliance indeed ; 
one that with a constant stream of water performs 
its work perfectly. The above cut gives a sectional 
view of it. 

An instrument constructed by Dr. George B. Snow 



EXCLUSION OF MOISTURE. 



175 



for the same purpose gives promise of great useful- 
ness. In principle it is a compromise between the 
Gifford injector and the siphon. It requires for 



Fig. 74. 



Fig. 75. 




operation but a small amount of water — about one 
quart per hour. The water requisite for its work- 



176 FILLING TEETH. 

ing is contained in a reservoir holding about two 
quarts. 

This instrument is very efficient and uniform in 
its operation. It is shown in Fig. 74. 

The most efficient appliance of this kind is now 
attached to the fountain spittoon, which in its oper- 
ation leaves nothing further to be desired. See ac- 
companying illustration (Fig. 75). 

With either of these appliances, the mouth can 
be kept for any length of time entirely free from an 
excess of saliva. 

The rapid, easy and efficient application of the 
rubber dam is not attained without some manipula- 
tive skill and experience. It is prepared for dental 
purposes of three or four grades, in respect to thick- 
ness ; the thinnest is about as thick as a sheet of 
common commercial note paper; the other extreme 
would be represented by about six-ply of the same 
paper. 

This web should be made of rubber of the finest 
quality, and free from all foreign substances. Hav- 
ing selected that of the desired thickness, cut a piece 
six inches wide and from six to ten inches long; select 
the proper place or places for perforating it for the 
teeth ; for this, three sizes of punches will be re- 
quired : one about a line and a half in diameter, for 
the molars ; one about a line in diameter, for the 
superior incisors and bicuspids, and one half a line,. 



EXCLUSION OF MOISTURE. 



177 



for the inferior incisors, and sometimes for small 
superior incisors. 

These punches are shown in Fig. 76. A prefera- 
ble form of punch is presented in Ainsworth's rub- 
ber darn punch, shown in Fig. 77. It consists x)f a 

Fig. 76. 




general forceps-form, having attached to one of the 
jaws a solid cone punch, which cuts the rubber 
against a perforated die, which is placed upon the 
other jaw ; this die revolves so as to bring each hole 
with a stop under the cone ; there are four holes of 

12 



ITS 



FILLING TEETH. 

Fig. 77. 




EXCLUSION OF MOISTUEE. 179 

graded sizes. This is by far the most efficient in- 
strument yet devised for this purpose. The distance 
between the holes in the cloth should be from one 
line to two lines and a half, governed by the dis- 
tance between the necks of the teeth to which it is 
to be applied. 

The following accessories should be at hand and 
ready for use before beginning its application to the 
teeth : 

Silk Thread. — That known as surgeons' or sad- 
dlers' silk is well adapted to the purpose. There 
should be at least two sizes of this. 

For some cases the floss silk is better adapted 
than the thread. These should always be at hand. 

The clamps for rubber dam are indispensable ; they 
are of various forms and sizes, and are now made 
adapted to all teeth ; and in addition there is quite a 
number of extras for special cases. 

The following cut represents the set for the supe- 
rior teeth of the right side, each of which has been 
formed and adapted to the respective tooth upon 
which it is to be used. 

There are in the full set thirty-two^ and a few for 
special cases, thus making by far the most complete 
and efficient series of these clamps ever devised. 

The profession is largely indebted to Dr. Delos 
Palmer for the most efficient clamps that have been 



180 



FILLING TEETH. 



in use for several years, and wholly indebted to him 
for the very perfect set represented below. 

The clamps are usually placed on the teeth, after 
the rubber-cloth is drawn over them, for the pur- 
pose of retaining it in a proper position. Often- 
times, however, the rubber^ may be drawn over the 



R. S., 1 



R. S., 4. 




R. S., 5. 





clamp, and then both together be placed upon the 
tooth. This method is usually employed only when 
one tooth is to be protected. 

For this adjustment upon the teeth, clamp-forceps 
are in requisition. They are so formed as to pass 
into the curve of the clamp, and by pressure upon 
the handles, open it sufficiently to pass on to the 
crown of the tooth, the rubber then being drawn 
under the jaws of the clamp. 

Fig. 79 represents the clamp-forceps in common 
use. 



EXCLUSION OF MOISTURE 

Fig. 7 { 



181 




182 



FILLING TEETH. 



The elastic strap, with clamps or catches attached, 
is necessary for holding away the upper free portions 
of the rubber cloth (Fig. 80). 



Fig. 80. 





The weights, also, for holding out of the way the 
lower free portions of the rubber cloth, are used by 
many. These are shown in Fig. 81. The work of 
the ordinary rubber dam clasps and weights is much 
better done by the little appliance found in notion or 
furnishing stores, called the sleeve elastic ; it consists 
of an elastic band three or four inches long;, with a 



EXCLUSION OF MOISTURE. 



183 



spring clasp upon each end, the beaks of which are 
serrated, so that they retain a firm hold of anything 
to which they are attached. They can be obtained 



Fig. 81. 






at any gentlemen's furnishing store for a few cents 
per pair; they are easy of application and really 
supersede any other appliance for holding the rub- 
ber dam. 



It is shown in Fig. 82. 



Fig. 82. 




Various sizes and forms of wedges will be required; 
these should be prepared beforehand, or they may 
be made at the time they are to be used ; their adap- 
tation to the peculiarities of the case in hand rather 
favors this course. 



184 FILLING TEETH. 

Javvis separatoi^s should always be at hand, to 
press apart any teeth that may stand so firmly in 
contact as to prevent the rubber from passing readily 
between them. 

Fig. 83. 




Having now come to that point when the rubber 
dam is to be applied, various questions and consider- 
ations occur : 

First — Upon how many teeth shall the dam be 
placed ? 

The character of the operation will determine this. 
For a simple crown cavity of either a superior or 
inferior molar, if the opening of the mouth is capa- 
cious, the embrace of one tooth may be, and often is, 
sufficient. If, however, the mouth be small, or the 
tooth unfavorably located, two or even three teeth 
should be included, even for such a cavity as just 
indicated. For filling proximate cavities, two or more 
teeth should always be included, and more frequently 
three or four. The difficulties liable to occur from 
the embrace of an insufficient number are, encroach- 
ment of the cloth upon the locality of the operation 
(the size of the mouth and its behavior will modify 



EXCLUSION OF MOISTURE. 185 

this, however), and the liability of leakage about the 
last teeth included in the embrace. 

A sufficient number should in every case be in- 
cluded to meet the requirements, and no more. The 
practice of placing the rubber upon eight or ten 
teeth, when two or three at most would be sufficient, 
should not be encouraged or allowed. It is a waste 
of time for the operator and an unnecessary annoy- 
ance to the patient. 

In the application of the dam, if it is to be put 
upon two or more teeth, it should first be placed 
upon that tooth which is most accessible, then upon 
the next one, and so on till all the selected ones are 
included. As the rubber is drawn over the crown of 
each tooth, the thread or floss should be passed be- 
tween it and its neighbor, carrying down to the 
margin of the gum the rubber that is between the 
holes ; this process should follow the application of 
the rubber to each tooth. 

The rubber will often pass with difficulty between 
the teeth, either because of firm contact or because 
of roughness upon the proximate surfaces of the 
teeth, the latter sometimes causing tearing of the 
rubber. To meet the former difficulty, the sepa- 
rators (Fig. 83) may be used, and sufficient space 
readily obtained to afford an easy passage between 
the teeth, and a very thin saw for the removal of the 
roughness ; this, however, should never be applied 



186 FILLING TEETH. 

to the perfect surfaces of the teeth ; and in respect 
to the rubber, moistening it with a solution of fine 
soap, of proper consistence, will greatly facilitate its 
passage between the teeth. 

The rubber cloth now being upon the teeth, the 
elastic band with its clasps should be attached to the 
upper free border at each side, and drawn round the 
head sufficiently to keep them out of the way; then 
the thread, in connection with a small, properly- 
formed instrument, will be applied for turning the 
border of the rubber about each tooth down beneath 
the margin of the gum, the thread accomplishing this 
between the teeth and the instrument, at the labial 
and lingual surfaces. This is a part of the work 
that should be carefully and thoroughly performed ; 
the absolute exclusion of the moisture depends much 
upon this. Ligatures are sometimes tied tightly round 
the necks of the teeth, for the purpose of holding 
the rubber in place about them; this, however, is sel- 
dom required. 

After this, the wedges, if required, should be in- 
troduced. The objects to be gained by these are, — 
increase of space between the teeth ; to retain the 
septum of the rubber against the gum, and press the 
gum up somewhat, and thus effect greater security 
against the encroachments of moisture ; and to pro- 
tect the gum from injury by the instruments which 
are to be subsequently used. 



EXCLUSION OF MOISTURE. 187 

The elastic clasps should now be applied to the 
borders of the rubber, in such a manner as to keep 
them in a desirable position. With the rubber dam 
thus adjusted, and the "saliva extractor" in proper 
order and in place, there will be no difficulty with 
moisture or an overflow of saliva in any case, and 
the succeeding steps may be conducted with the ut- 
most security, so far as moisture is concerned. 

Some operators apply the rubber dam in almost 
every instance prior to the removal of decay and the 
formation of the cavity for filling ; and doubtless in 
many cases it is the preferable course, the only ob- 
jection to it being the prolonged inconvenience to 
the patient ; but for this there is perhaps full com- 
pensation, in the greater facility afforded in the re- 
moval of decay from and the excavation of the cav- 
ity ; with the entire absence of saliva and moisture, 
the work can be effected with greater rapidity and 
precision ; improper cutting is less liable to occur, 
and less pain is given to the patient. 

After the rubber dam is properly adjusted, it is an 
easy matter, with bibulous paper or some similar sub- 
stance, to render the tooth and the part to be operated 
upon thoroughly dry. Every particle of debris, cut- 
tings of dentine, etc., should be removed from the 
cavity before it is filled. This removal may be 
effected by the small scoop-shaped instruments, of 
which there should be three or four sizes. In con- 



288 



FILLIXG TEETH. 



nection with these, the " chip blower" or warm air 
blowpipe, illustrated in Fig. 84, may be advantage- 
ously used. 

This instrument consists of a small blowpipe, with 
a cylinder an inch long and half an inch in diameter ; 
this is placed down within two inches of the point 
of the instrument. This cylinder is either made of 
very heavy metal, or filled with wire or something 
that will retain heat ; on. the other end is attached a 

Fig. 84. 




stiff india-rubber ball, with an eyelet opening, one- 
fourth inch in diameter. By placing the thumb upon 
this opening and making compression, a jet of air is 
forced through the point of the pipe, and the cylinder 
being previously heated, the temperature of the jet 
will be governed by that of the cylinder, and the 
velocity with which it is forced through the instru- 
ment. This jet thrown in a cavity that has been 
made as dry as possible by wiping, soon makes a 
very perceptible change, the walls becoming whiter 
than before. This we consider the most desirable 
condition in respect to dryness that can be obtained. 



INTRODUCTION OF THE FILLING. 189 

Introducing the Filling. 

Having in all these steps for the preparation of 
the cavity made thorough work, the next thing to be 
accomplished is the introduction and consolidation 
of the filling. The manner of performing this part 
of the work will be governed by the kind of material 
employed, and also, somewhat, by the form of the 
particular material, as well as the method adopted. 
Some materials, as gold, for instance, may be used in 
six or eight different forms, each involving a prin- 
ciple peculiar to itself; and each of these forms is 
susceptible of being used in different ways. It is 
proposed to describe, as clearly and concisely as 
possible, the various methods of filling that have 
been found efficient. This is the more important, 
since different operators differ in their election of 
methods ; some preferring one, others another, — the 
result of mere choice, habit, or some peculiar fitness. 

The first method for consideration is that of filling 
with ordinary non-cohesive gold foil. The principles 
applicable to the use of this kind of foil also obtain 
in the use of foils of other metals. Gold is used far 
more than anything else. The common, and, indeed, 
the almost universal method of using foil, in the early 
periods of the profession, was in the form of a roll, 
or rope, as it is sometimes called. By this method 
the foil is cut into strips from one-third of an inch 



190 FILLING TEETH. 

to two inches wide, the width being governed some- 
what by the size of the cavity to be filled. This 
strip is then rolled lengthwise, forming a loose roll. 
The compactness of the roll should depend upon the 
thickness of the foil, and the size of the points with 
which it is to be condensed ; the smaller the points, 
the more compact the roll may be. 

It may be introduced either with the condensing 
instrument or with the plugging pliers. If with the 
former, it is taken up at one end on the point 
of the instrument, and passed to the bottom of the 
cavity ; and that portion within the cavity is then 
pressed firmly against the wall where it is desirable 
to begin the filling. There is no definite uniform 
point in the cavities at which to begin the introduc- 
tion of the gold ; usually, however, in crown cavities 
of the molars, at the posterior wall. At whatever 
point the filling is commenced, the cavity should be 
so formed that it will retain in position the first por- 
tion of gold introduced; and this may be done by form- 
ing a little pit or groove for its reception. This is a 
particular that cannot with impunity be neglected. 
The gold should never change its position after it is 
pressed to the wall of the cavity ; for its position 
cannot be changed, except at a sacrifice of the adapta- 
tion, after it is condensed. The end of the roll being 
placed in the cavity, it is seized far enough without 
the cavity to form, a fold that will extend to the 



INTRODUCTION OF THE FILLING. 191 

bottom, and protrude about one line beyond the 
border of the orifice. This fold is pressed firmly 
upon the preceding portion of gold and adjacent walls. 
Thus fold after fold is introduced, passed to the bot- 
tom of the cavity, and, protruding from the orifice,, 
consolidated firmly : each portion as it is introduced 
should be well adapted to the walls of the cavity 
and the preceding portion of the filling. 

It is important to obtain as complete an adaptation 
of the filling to the walls of the cavity as possible - r 
and in order to accomplish this, the centre should 
not be filled too rapidly. The gold is thus introduced 
fold after fold till the cavity is full. When it is filled 
to two-thirds of its diameter, the gold should then be 
adjusted to all the remaining walls of the cavity, and 
the last portions of gold introduced somewhere in 
the body of the filling, certainly not next to any wall 
of the cavity. A more thorough adaptation of the 
gold can be made to the walls of the cavity by this 
manner of arranging it than by introducing the last 
portion at one side of the cavity. There is less lia- 
bility of fracturing a frail tooth by placing the gold 
on the walls first, and terminating the introduction 
of it at or near the centre of the filling. It is the 
practice with some to introduce the gold rather 
loosely, cr without much condensing, and after being 
introduced in this manner, to condense by forcing 
into it a wedge-shaped instrument at various points, 



192 FILLING TEETH. 

and filling these perforations with small rolls of gold, 
continuing to use the wedge-shaped instrument as 
long as it can be forced into the filling. This method 
is by no means as efficient as that of condensing each 
portion as it is introduced. By the latter plan the 
filling can be made uniformly dense from the surface 
to the bottom. This cannot be done by the use of 
the wedge-shaped instrument ; it will compress most 
at its largest diameter, that is, at the surface of the 
filling. 

In no filling, even when the walls of the cavity 
are parallel, will a uniform density throughout be ob- 
tained by perforating with the wedge-shaped instru- 
ment. The filling would be most dense at the sur- 
face, and gradually less so all the way to the bottom. 
This method is objectionable for condensing the fill- 
ings on the masticating surfaces of the molars; 
for in the act of mastication the inner portion would 
yield, the surface of the filling would be crowded 
down into the cavity, and the dentine within the 
orifice become exposed, and decay be the result. In 
proximate fillings, this objection would not have the 
same force. In pressing an instrument of a wedge 
form into a filling with sufficient force to condense 
the mass, there would be great danger of breaking 
a weak wall of the cavity. The principal pressure 
is lateral, and would consequently come upon the 
side of the tooth. 



INTRODUCTION OF THE FILLING. 193 

In crown cavities of the molars, where there is any 
considerable inward expansion of the cavity, that 
method of condensing would be wholly inefficient; it 
would not render the inner portion dense enough to 
support the surface of the plug, and it would be 
forced down, and necessarily be loose. In filling the 
proximate cavities of the incisors, it is very objec- 
tionable on account of the great liability of break- 
ing the inner and outer walls, which are usually 
quite thin. 

In preparing the foil for filling, some operators 
tear off the foil in irregular pieces, and form, these 
into little balls or pellets, round and loosely rolled, 
corresponding in size with the cavity to be filled. 
These pellets are placed in the bottom, if a crown 
cavity, and at one side if a proximate cavity, and con- 
densed with a sharp-pointed instrument, attaching 
one pellet to another till the cavity is full. This 
mode is not so good as that previously referred to, 
unless the gold is in a condition to weld perfectly ; 
there is no continuous portion from the bottom to 
the orifice of the cavity, and the outer portions are 
liable to become detached. Both of these methods 
of arranging the gold are objectionable in one par- 
ticular, namely, the irregularity of the leaves of the 
foil ; these are placed in the cavity without regard 
to regularity, and the consequence is that, without 
great care, far less gold will be introduced than by 

13 



194 FILLING TEETH. 

some other arrangement. Much more difficulty is 
experienced in obtaining a uniform and equal density 
than when the laminae are placed smoothly together. 
Another method of preparing the foil is to fold it 
into from four to twelve thicknesses, then cut off 
strips in width corresponding to the diameter of the 
cavity. The strip thus prepared is introduced in the 
same manner as the roll, except that as each fold is 
inserted, it is placed smoothly against the preceding 
portion, and kept smooth and free from wrinkles. 
By this arrangement very little force is required to 
bring the folds in perfect contact. Some care and 
skill will be necessary to bring the instrument to 
bear upon the whole surface of the fold. More gold 
can be put into a cavity in this manner than in rolls 
or pellets, unless these are used in small portions and 
condensed thoroughly as they are put in. 

Cylinder or Block Filling. 

Another and in some respects far preferable 
method, is filling with cylinders or blocks. Some 
of the advantages of this method over that just de- 
scribed are the following : the filling can be intro- 
duced far more rapidly ; and the laminae, or leaves of 
foil, take a more perfect position in the cavity, and 
consequently the structure of the filling is better. 
The form of the cavity should be much the same as 



CYLINDER OR BLOCK FILLING. 195 

that for any other method of filling ; there should be 
some retaining-point so situated that the first bloc^;, 
or blocks, can be fixed firmly in place, so that there 
will be no liability of loosening during the subsequent 
part of the process. It is important to have such .an 
arrangement, as otherwise it would be necessary to 
employ an instrument in the left hand to retain the 
first blocks in situation, till enough were introduced 
to bind the whole by pressure upon two opposite 
points in the cavity. 

Forming Blocks. — For forming blocks, use any 
number of foil that may be desired, usually, No. 4 
or 6, and either lay four or six sheets together, or 
fold a single sheet into that number of thicknesses; 
then cut off from the sheets thus prepared strips 
about one-third to one-fourth wider than the depth of 
the cavity to be filled ; these are then rolled on a 
small three or four-sided broach — the three-sided is 
better. This instrument should be very small — no 
larger, indeed, than is necessary for strength. Its 
sides should be perfectly smooth, and its angles 
sharp ; ordinarily it should not taper, or at least but 
slightly. For forming the conical blocks, some pre- 
fer the tapered broaches, but they can be as well 
made on the parallel-sided instruments. The strip 
being taken between the thumb and the index finger, 
is rolled on the broach equally, till the block or cyl- 
inder is large enough, when the strip is broken off. 



196 FILLING TEETH. 

The size of the principal part of the blocks should be 
determined by the size of the cavity to be filled. Dif- 
ferent sizes and forms will be required in almost every 
case. Relatively large cylinders may be employed for 
the principal part of the filling. If the walls of the 
cavity are parallel, almost all the blocks may be cyl- 
indrical ; but if there is an under-dipping of one 
or more of the walls, the blocks adjusted to that par- 
ticular part should be cone-shaped, corresponding to 
that under-dipping. A number of small graduated 
cone-shaped blocks, of different degrees of density, 
will be required for completing each filling; as the 
aperture becomes smaller, smaller blocks will be 
needed. The cone-shaped blocks are formed by grad- 
ually running the strip back from the point of the 
instrument as it is wound on ; greater or smaller 
taper can be given to it as the strip is run less or 
more rapidly back from the point. The density of 
the block can be regulated by the firmness with 
which the strip is held between the thumb and 
finger, upon which it is well to have a suitable cov- 
ering, to protect the gold from the perspiration of the 
hand. There are other methods of forming blocks. 
Cylinders and blocks are prepared by foil manufac- 
turers, in sufficient variety, in respect to size, form, 
and density, to meet all cases; they should always 
be at hand. Fig. 85 represents cylinders and blocks 
as prepared by foil makers. They may be made 



CYLINDER OR BLOCK FILLING. 197 

square, by making a great number of folds — fifteen 
to thirty — and from this cutting strips as before di- 
rected, and then from these heavy strips cutting off 
the blocks of the desired size, which will then be Hat 
or nearly square. In one respect these blocks are ob- 
jectionable. The edges when they have been cut 
off are rendered dense by the action of the shears, 
so that they do not possess the uniform density or 
consistence of the rolled blocks or cylinders and it 
is impossible to adapt them as perfectly to the walls 
of the cavity, or to one another. This objection, how- 

Fjg. 85. 



ever, may be obviated by cutting off the blocks with 
a very fine knife, such as is used by the foil makers. 
A good method of making pellets is to form with a 
napkin, a sheet, or part of a sheet of foil, of any 
desired thickness, into a roll of proper density, and 
cut from it blocks or pellets, the length of which 
may be indicated by the size of the cavity to be filled. 
These are liable to the same objection as those last 
mentioned, the shears hardening them when they 
are cut off. They are subject to the additional 
objection, that the folds of foil are not as regular 



19fr PILLING TEETH. 

as by either of the other methods. But by proper 
manipulation, with the gold prepared in this manner, 
superior fillings may be made. Another method of 
preparing blocks is by cutting a sheet of foil into two 
or three pieces, then rolling them diagonally on a 
steel wire or rod ; the size of this wire will be deter- 
mined by the required length of the blocks ; as there 
should be blocks of different lengths, the wires should 
be of different sizes, and range from No. 2 to No. 12 
of White's bur gauge plate. The size of the wire will 
be determined by the depth of the cavity. The wire 
being withdrawn, the roll is compressed to a strip. 
These strips are now rolled squarely upon a No. 20 
steel wire, the size of the cylinder being determined 
by the size and form of the cavity to be filled. 
These may be used either in their cylindrical form 
or compressed and doubled. The cavity formed and 
the blocks prepared, the next step is their introduc- 
tion. 

Introducing the Blocks. — For placing the gold into 
the cavity, the plugging pliers are required, the 
points of which should be curved, so as to make the 
most direct approach to the cavity. The points, too, 
if properly formed, may be used to some extent for 
condensing the gold. All things being ready, the 
cavity secured against the encroachment of moisture 
from the saliva and breath, the left hand should be 
employed to keep the rubber and the soft parts of 



CYLINDER OR BLOCK FILLING. 199 

the mouth in position. If there is an angle, a small 
block should be first introduced with the pliers into 
the proper position, one end upon the bottom of the 
cavity, and the other protruding from the orifice, and 
pressure then be made to consolidate it, and force it 
into its position against the wall of the cavity. This 
may be done with the pliers, or better with the 
instrument represented b}^ Fig. 34. The part of the 
instrument brought to bear upon the gold should be 
roughened either longitudinally or transversely, so 
that a proper surface may be left for the reception of 
the succeeding portions. The largest blocks are then 
introduced and consolidated successively as described, 
the end of each left protruding till the cavity is 
filled ; each portion as it is introduced should be per- 
fectly condensed. The gold should be filled in at 
the sides of the cavity in advance of the centre, thus 
being disposed round the walls till it meets at a 
point opposite the place of beginning; and thus the 
gold is adapted to all the walls of the cavity before 
it is entirely filled, the last portions being introduced 
somewhere near the centre of the filling. As the 
cavity diminishes by the introduction of the gold, the 
small and more dense blocks will be required ; these 
should be forced in and condensed, by crowding the 
instrument (Fig. 36) down against the side of the 
cone. Some operators terminate the filling against 
the wall of the cavity, forcing down the blocks and 



200 FILLING TEETH. 

compressing as above, till it is full. By this method 
there is danger of fracturing the tooth, breaking 
down the wall of the cavity, where the filling is ter- 
minated. Another method is to fill up the cavity 
principally with blocks, and to put in the last part of 
the filling in the strip, filled in from the bottom to 
the orifice. The objection to this method is, that 
unless adhesive foil is employed, the portion inserted 
in the strip is liable to be displaced, and in this way 
the whole filling become destroyed. 

Another method of arranging this kind of filling, 
particularly when the bottom of the cavity is irreg- 
ular, is to make a large, flat pellet, condense it firmly 
to the bottom, and set the blocks upon this for a 
foundation. By this method there is a more perfect 
adaptation of the gold to the bottom of the cavity, 
than by placing the ends of the blocks down upon an 
uneven surface. After the gold is all introduced, a 
small-pointed plugger must be passed over the entire 
surface, to consolidate the protruding portions. These 
protruding portions should be sufficient to make the 
surface, after being condensed, perfectly flush with 
the border of the cavity, for a depression here is 
fatal to a complete finish, except by the addition of 
cohesive gold. After the condensation with the finely 
serrated points, then the blunt, smooth, polished, 
points should be used with the mallet aU over the 
surface of the filling, then the files, burs, stones, etc., 



PELLETS. 201 

of the various grades should be used to complete the 
finish. 

Dr. Badger described a method of filling a small 
cavity on the posterior proximate portion of a second 
molar, the third molar gone. The cavity is formed 
with a bur drill. A cylinder is then formed in the 
usual manner, and forced through a series of holes in 
a drawplate, down to the size of the bur with which 
the cavity is prepared. The block is thus rendered 
quite dense. The cavity is then dried, and the block 
forced into it, which it exactly fits, protruding a little 
from the orifice. This block is pierced in the centre 
with a sharp instrument, and a small dense roll 
forced into it ; all is then condensed, and finished in 
the usual manner. 

Pellets. — Pellets made by rolling fragments or 
pieces of foil between the thumb and fingers are used 
by some operators, and with them they profess to 
make as good filling as by any other method. They 
are made of various sizes, and packed into the cavity 
with sharp-pointed or serrate-pointed instruments. 
The pieces may thus be very solidly worked together, 
and a good filling made, provided the pellets are not 
too large ; they should be small enough to permit the 
point or points to work through them into the preced- 
ing portions. Some operators use pellets and crys- 
tal gold together. This may do very well if the co- 
hesive property of the gold is employed ; but in that 



202 FILLING TEETH. 

case, either form of the material would answer alone. 
There cannot be as much gold put in by pellets as by 
blocks or cylinders well adjusted. 

Cohesive Foil. — By this is understood that condi- 
tion of gold foil in which the leaves unite readily 
and firmly together. This property of cohesion is 
possessed in the greatest degree by properly manu- 
factured foil, immediately after annealing. Not that 
annealing imparts any new property to the gold, but 
it removes obstacles to the manifestation of a prin- 
ciple possessed by all gold under favorable circum- 
stances. It is now about twenty-five years since this 
property was first employed in gold foil for filling 
teeth. To Dr. R. Arthur is due the credit of first 
directing the attention of the profession to it, as 
being available for filling teeth. He not only did 
this, but he entered most fully into the details of the 
manipulations, instruments, etc., pertaining to this 
mode of operation. Almost all recently-prepared 
gold foil possesses this property to a greater or less 
degree ; there are methods of preparing it, however, 
by which it possesses it more fully ; all recently 
annealed foil is cohesive. If the foil is in this con- 
dition when we wish to use it, nothing further is 
required in the way of preparation. But if it is not 
cohesive, — as almost all foil is not, especially if it has 
been much exposed to the influence of the atmo- 
sphere, — it will require to be made so by some pro- 



COHESIVE FOIL FILLING. 203 

cess. There are two methods, either of which will 
well accomplish the object. 

The one most frequently employed is that of heat- 
ing the gold, either in the sheet, in the roll, or in 
fragments, over the name of a. spirit-lamp, almost or 
quite to a red heat ; if in the sheet, it should be laid 
upon a piece of wire gauze, and passed over the 
flame of the lamp for a moment or two ; if in the 
roll, it may be taken in the centre with fine pliers 
and passed rapidly through the flame. But if the 
gold is in the form of pellets, blocks, or cylinders, or 
small pieces of any shape, it may be taken up with 
the pliers and passed rapidly through the flame of a 
spirit-lamp, till all foreign substance is burned or 
driven from it. Or it may be placed on a sheet of 
mica, which is adjusted over a flame, and then 
brought to a proper temperature. 

There are different methods of using gold in this 
condition ; but in general the cavity should be formed 
about as for the other methods of filling, except that 
at some point or points the cavity should be formed 
so as to retain firmly the first portion of gold intro- 
duced ; such anchorage should be located with refer- 
ence to convenience, and the strength of the tooth. 
The first portion of gold should be a little pellet ; 
this, forced into these retaining spaces, serves as a 
foundation for the remaining portion of the filling. 
Dr. Arthur's method is, then to tear off fragments 



204 FILLING TEETH. 

from the sheet, and pass it into the cavity without 
folding, and condense it with an instrument of finely 
serrated point, so that it not only unites by cohesion, 
but is worked into the surface of the preceding por- 
tion of gold; and in this manner portion after por- 
tion is introduced and condensed, until the cavity is 
full. The filling may be commenced in any part of 
the cavity that is most convenient ; in many, as in 
crown cavities of the molars, at the bottom, and filled 
to the orifice. In putting in the gold, it should dur- 
ing its introduction, be kept fuller about the walls of 
the cavity than in the centre ; by this means the 
adaptation will be most perfect to the walls, and 
there will be no liability of clogging in the centre. 
The gold may thus be built up to any desired extent 
if the filling is kept dry ; moisture is fatal to its co- 
hesion. 

Others use the cohesive gold in a different manner. 
To Dr. Blakesley belongs the honor of first detail- 
ing the following plan : The sheet of gold may be 
folded or not, at the pleasure of the operator, and then 
each sheet cut into from two to six strips, and each 
of these formed into a loose roll between the thumb 
and fingers. These should now be passed through 
the flame, as already described, then cut into little 
blocks or pellets of various sizes ; these to be regu- 
lated by the size of the roll and the cavity to be 
filled. For the introduction of the gold thus pre- 



COHESIVE FOIL FILLING. 205 

pared, about three sizes of instruments are required, 
those having finely serrated points being preferable. 
As to the size of these points, Dr. Blakesley remarks, 
"They should just enter respectively Nos. 22, 24, 
and 26 of the wire-gauge." A larger than either of 
these, however, is desirable for many cases. As be- 
fore, the filling may be commenced at the bottom 
of a cavity, or at one side, if desirable, with a 
pellet sufficiently large to be set firmly into the re- 
taining space. Then take up the small pellets or 
blocks upon the point of the plugging instrument, 
and place them exactly in the desired position, and 
consolidate them thoroughly, building up next to the 
wall all around higher than the centre, with the 
smaller pieces filling up the little corners and inter- 
stices, for which manipulation the smaller points will 
be required. The gold is then packed in till the 
cavity is full, when it is finished as usual. Another 
method is to tear off fragments from the sheet and 
roll these into round pellets, and fill with these with 
the same instruments and upon the same principle 
as above described. But by this method it is difficult 
to make a perfect filling; the gold is liable to clog in 
the cavity and fail in adaptation. 

Cohesive gold must be consolidated as it is intro- 
duced, for, if a cavity is full, it is very difficult then 
to condense it more, even though the consolidation 



206 FILLING TEETH. 

is but partial; and the same is true, to some extent, 
of non-cohesive foil. 

The Mallet. 

In the year 1860, Dr. W. H. Atkinson introduced 
to the dental profession the mallet for the purpose 
of condensing gold in filling teeth. This effected 
quite a change in the theory and practice of this 
part of the work. Prior to this period it was accom- 
plished entirely by the pressure or force exerted by 
the hand. There was very considerable diversity of 
opinion as to the best mode of this manipulation, 
some maintaining that great force is always required 
to make a filling sufficiently dense, assuming that it 
is better to use comparatively large points, great 
pressure and rapid execution, thus securing the ut- 
most economy of time, both to the operator and pa- 
tient. Others entertain the opinion that with smaller 
points, less pressure, and greater time, a more definite 
and satisfactory result is attained. 

Notwithstanding the diversity of opinion and prac- 
tice upon this subject, we would suggest that young 
operators, at least, should bear in mind that in so 
important a matter as filling teeth efficiency should 
never be sacrificed to rapidity. 

This method is especially applicable and effective for 
the condensation of cohesive gold, and, indeed, gold in 



THE MALLET. 207 

any form, when the aim is to condense each portion 
as it is introduced. A more thorough condensation 
is made by the use of the mallet than is possible by 
the hand alone; greater precision of manipulation is 
attainable; it is easier for the operator, and usually 
less unpleasant to the patient. 

The character of the results in the use of this in- 
strument depends much upon the skill of the assist- 
ant. It requires time, care, and patience to familiar- 
ize an assistant with the use of the mallet. The 
plugger should be held firmly in position by the op- 
erator, and receive the stroke squarely upon the end ; 
it should be a sharp, springing tap. Yery much de- 
pends upon the character of the blow; a dead, heavy 
stroke will not unite the gold as it should be. It is 
important that the assistant be able to follow the in- 
dications of the operator without loss of time. Many 
assistants are disposed to give time strokes instead of 
following indications, which are not admissible ex- 
cept in very simple cases. 

In order to avoid the employment of an assistant 
and to place the strokes of the instrument more under 
the control of the operator, various forms of auto- 
matic mallet p luggers have been invented and con- 
structed. Two or three principles embrace the whole, 
though many different forms have been made. Those 
operated by the action of spiral springs have been 
the more common; the objection to almost all of 



208 



FILLING TEETH. 



these is, that the stroke lacks the desired elasticity. 
This class of instruments is represented in general 
aspect by Fig. 86. 

This instrument was invented by Dr. I. A. Sal- 
mon, and is one of the best of this form; it operates 
well in the hands of those who become familiar 
with it. 

An instrument was, some years ago, made by Dr. 
S. B. Palmer, in which the force of the blow is placed 
completely under the control of the operator while it 



Fig. 86. 



is being used. The operation of this instrument is 
perhaps less objectionable, in respect to the character 
of the stroke, and its control by the operator, than 
any other as yet employed. Any of these instru- 
ments are valuable in the hands of those who become 
familiar with them. 

During the last few years efforts have been made 
to operate the mallet by various motors. The first 
attempt in this direction was by Dr. G. W. Bon will,, 
by the application of galvano-electricity. The first 
machines were very crude and unsatisfactory; but 
by improvements made from time to time, the in- 
strument is quite efficient in the hands of those fa- 
miliar with it. 



CRYSTAL OR SPONGE GOLD. 209 

A mallet has been invented and constructed by- 
Professor T. L. Buckingham, designed to be attached 
to and operated by the dental engine. It is more 
under the immediate control of the operator than 
most of the automatic mallets in use. This is highly 
prized by many. The pneumatic mallet was devised 
by Dr. W. H. Jackson. This consists of an ingenious 
and yet simple application of air as a motor. For a 
description of each of these, with illustrations, see 
Appendix of this work, Section C. 

Crystal or, Sponge Gold. 

The form of the cavity for crystal gold filling 
should be much the same as that described for other 
fillings, except that the same care is not necessary for 
special retaining-points, for the first portion of good 
crystal gold that is introduced into the cavity will at- 
tach to the walls without any such provision. Such 
a form should be given, however, as to secure the first 
piece firmly in place. The gold should be cut or 
broken into pieces corresponding in size to the cavity, 
so that they will enter freely into it. 

The filling may be commenced upon the bottom of 
the cavity, or upon one of its sides ; such a point al- 
ways being selected as will most effectually retain the 
gold in place. The pluggers should be of various 
sizes, the first one as large as can be used freely in the 

14 



210 FILLING TEETH. 

cavity, and smaller ones for condensing more thor- 
oughly, and all should be serrated. The blocks may 
be taken up on the point of the plugger, or perhaps 
better with the pliers, and passed to the proper posi- 
tion in the cavity, and there condensed. The sharp 
serrated point leaves the surface in good condition for 
the reception of the next piece. The gold should be 
packed to the walls of the cavity a little in advance of 
the centre, so .that its adaptation may be more com- 
plete. In this manner the filling is built up as much 
as is desirable, if it is kept dry, and unless it is, cohe- 
sion is very much diminished or lost altogether. 

The gold, after it is cut, is passed through the flame 
of a spirit-lamp, to anneal it, and dispel all foreign 
substances. It should in no case be brought above a 
perceptible red heat, and usually not to that point ; 
it should be done carefully, so as not to fuse any of 
the particles, as that would impair their facility of 
cohesion in this process. Small portions are often re- 
quired to fill up small interstices, or notches. 

In crown cavities, the filling should begin at the 
bottom ; in proximate cavities, at the cervical wall. 
By introducing the gold in this manner, the pressure 
is made on a line with the axis of the tooth, which is 
an important consideration. The surface of the filling 
should be made to conform to that of the lost portion 
of the tooth ; this can always be done except where 
the tooth is largely broken away, and even then very 



CRYSTAL OR SPONGE GOLD. 211 

much may be accomplished in many cases to restore 
the lost form ; that will depend, however, upon the 
method of using the gold, and the security of the at- 
tachment for it. In crown fillings of the molars and 
bicuspids, the antagonism of the teeth must be regarded ; 
they should be formed for the reception of the cusps 
of the opposing tooth. Proximate fillings should usu- 
ally be convex ; yet many good fillings of this class 
are made with a surface perfectly plain with the bor- 
ders of the cavity. The borders of the filling, however, 
are better protected when it is somewhat convex. 

Crystal gold, of perfect character, presents to the 
walls of the cavity a surface better calculated to be re- 
tained than foil in any of its forms ; though cohesive 
foil possesses this advantage to a greater extent than 
foil in any other condition. The points and edges of 
the crystals are brought in contact with the wails, and 
take a firmer hold upon the dentine. 

In forming crystal gold into a solid mass, two prin- 
ciples are operative : cohesion acts upon it as potentially 
as upon gold in any other form, and, in addition, there 
is the interlacing, or locking, of the crystals with one 
another ; so that a more perfect union of the different 
portions of which a filling is composed is obtained with 
crystal gold than with foil. Yet good cohesive foil, 
when properly manipulated, attains almost the same 
condition. 

It is important to keep the gold perfectly free from 



212 



FILLING TEETH. 



moisture while being introduced and consolidated ; for 
moisture instantly destroys its cohesive property. And 
the more complete the exclusion of moisture from the 
cavity during the process, the better for the success of 
the operation. The surface of every filling should be 
consolidated for finishing before it is allowed to become 
moist, for if it becomes saturated with moisture before 
consolidation, it is impossible to make a perfect finish. 



Fig. 87. 




f? 




O ^ 



There should always be gold enough superadded to in- 
sure this ; and the consolidation of the surface should 
be effected with a burnisher of the proper form, used 
with the mallet, consolidating the entire surface as 
thoroughly and smoothly as possible, exercising great 
care about the borders of the filling. Fig. 87 repre- 
sents the forms of the burnishers suitable for almost 
all cases. 



FINISHING FILLINGS. 213 



Finishing Fillings. 



The method of finishing a filling, and the manipu- 
lation required, will depend somewhat on its locality. 
When the filling has been thoroughly consolidated 
over all the surface, and especially all round its border, 
the file may be applied to dress off any projecting por- 
tion, and render it smooth. In consolidating the sur- 
face, an instrument should be used that would not 
pit it, and the file or finishing bur should remove all 
indentations. The work of these, however, should be 
but partially performed at first, and the surface bur- 
nished again. To obtain the most perfect finish, the 
surface should be brought to a uniform consistence ; 
and this condition cannot be reached by the use of 
sharp-pointed instruments, nor fully by that of the 
blunt plugger at the first effort, but by the alternate use 
of the file, corundum wheel or cone, the blunt condenser, 
with the mallet, and the burnisher. A coarse corundum, 
or bur should be employed in this part of the process ; 
but when the filling is dressed sufficiently, and in good 
condition, the fine corundum, Hindostan and Scotch 
stone should be used alternately with the burnisher, 
till a perfectly uniform surface is obtained. In all 
cases after the stone has been applied, the plug should 
be washed off with a brush, to remove all detached 
pieces of gold, before the burnisher is put upon it ; 
and after the Scotch or Arkansas stone, slips of the 



214 FILLING TEETH. 

proper form, used with the port-polisher, or very fine 
pumice, should be employed to remove the file-marks. 
The pumice may be applied with water on a strip of 
chamois skin, a piece of linen tape, or a stick of soft 
wood — the latter being the most convenient, as it can 
be used with one hand — shaped to suit any place or 
position. Emery cloth of every requisite grade of 
fineness is now obtainable ; this may be cut into strips 
of any desired width. It is very efficient for finishing 
all fillings in the proximate portions of the teeth. 

After the stone or the pumice has accomplished its 
work, and the filling has been thoroughly washed, a 
fine burnisher, with a solution of castile soap, may 
be used to give the finish. The burnisher should be 
of the best cast steel, and of high temper and fine 
polish. Considerable skill is requisite to give the best 
effect with the burnisher ; it should pass smoothly 
and gently over the surface, throughout its whole 
extent, and in parallel lines, with a pressure neither 
too light nor too heavy. It should also be applied 
very thoroughly upon any portion of the tooth about 
the border of the filling that may have been cut by 
the file or any other instrument. Indeed, quite as 
much, if not more, care should be exercised upon this 
as upon the plug itself: it should be polished as 
smooth as the enamel, if possible, for the more nearly 
perfect it is in this respect, the better will it resist the 
action of the deleterious agents. 



FINISHING FILLINGS. 215 

This method of finishing gives to the filling a per- 
fect metallic lustre, which under some circumstances, 
is objectionable. Two other methods are in use : 
After the burnisher has been applied, as above, the 
buff or tape, with rouge, may be employed, by pass- 
ing it rapidly over the filling, till the metallic lustre 
is destroyed, or deadened, so as not to reflect the light 
as before, thus leaving a very desirable finish ; and 
the other method is, to stipple over the surface of 
the burnished filling with the end of a piece of hard 
wood, — sandalwood is recommended, — charged with 
finely-pulverized pumice. This gives a beautiful, 
velvet-like surface, and is applicable to fillings in the 
anterior portion of the mouth, where they are ex- 
posed to view. Rotten-stone, applied either with 
the buff or with hard wood, imparts a finish which, 
although a little different, is equal to any of the 
others. 

For finishing, some operators prefer to cut and 
polish, instead of filing, stoning or burnishing. But 
neither so good nor so fine a finish can be effected in 
this way, and it is probable that economy of time and 
labor, especially the latter, suggested the method. The 
introduction and use of the corundum cones and 
disks, cones of Hindostan and Scotch stone, and the 
wood cones and buffs (represented on pp. 113, 114), 
all to be used with the dental engine, greatly facili- 
tate the work of finishing, and perhaps accomplish it 



216 FILLING TEETH. 

better ; but great care should always be exercised in 
the use of these implements. In all cases the filling 
should have a distinct and definite margin ; the gold 
should be trimmed off quite up to the border of the 
cavity, by passing round it a small sharp instrument 
so as to detect and pare down any portion that might 
overlap the tooth ; for if overlapping portions are 
permitted to remain, foreign substances will lodge be- 
neath, and induce decay. Neglect in this particular 
has occasioned the loss of thousands of teeth that 
otherwise might have been saved. This direction 
does not apply to those cases elsewhere mentioned, 
in which it is recommended to form a thick, firm over- 
lapping portion, for the protection of a thin febrile 
border. 

The subject of finishing is almost entirely over- 
looked by very many operators, but by the neat and 
skilful it is esteemed of sufficient importance to de- 
mand as great labor and pains as any other j3art of 
the work. 



CHAPTER VII. 

CLASSIFICATION OF DECAYED CAVITIES. 

The following classification of decayed cavities in 
the teeth, though from the very nature of the subject 
imperfect, will be found sufficiently accurate to aid 
the dental student and the practitioner. It is based 
primarily on the position of the cavities, and second- 
arily on the extent of the decay, — the classes having 
reference to the former and the modifications to the 
latter. The classes are numbered according to the 
accessibility of the cavities, beginning with those most 
easily approached and operated upon, and the modifi- 
cations according to the extent of the decay, begin- 
ning with the smallest and simplest in form. 

Fiest Class. — Simple central crown cavities in the 
molars and bicuspids. 

1st Mod. — Extension of the decay along one or 
more fissures or depressions. 

2d Mod. — Two decays in close proximity on the 
same crown, which may be formed into one cavity for 
filling. 

Second Class. — Cavities in the buccal and palatal 
surfaces of the molars and bicuspids ; and in the labial 
and palatal surfaces of the cuspids and incisors. 



218 CLASSIFICATION OF DECAYED CAVITIES. 

1st Mod. — Extension of the decay beneath the 
margin of the gums. 

2d 3fod. — Extension of the decay so as to involve 
a portion of the crown surface. 

Third Class. — Anterior proximate cavities of the 
bicuspids and molars. 

1st Mod. — Extension of the decay toward the neck 
of the tooth, beyond the termination of the enamel. 

2d Mod. — Extension of decay so as to involve a 
portion of the grinding or crown surface. 

Fourth Class. — Proximate cavities of the incisors 
and cuspids. 

1st Mod. — Palatal wall of the cavity broken away. 

2d Mod. — Labial wall broken away. 

3d Mod. — The cavity at the point of the tooth ter- 
minating at the surface. 

4th Mod. — The borders of the cavity very thin, and 
the lateral walls inclining to the centre. 

Fifth Class. — Posterior proximate cavities of the 
molars and bicuspids. 

Modifications same as those of third class. 

Modifications common to all classes : 1st. Super- 
ficial cavity and a large orifice. 2d. Deep cavity and 
a small orifice. 

Modifications common to classes three, four, and 
five. Transverse extension of the decay round one 
or more angles of the tooth, under the termination of 
the enamel. 



filling by classes and modifications. 219 

Filling by Classes and Modifications. 

Fiest Class — Central cavities of the molaes 
and bicuspids. — These decays always begin in the de- 
pressions on the masticatory surfaces, which are vul- 
nerable points, the enamel-membrane folding together 
here, and often being imperfectly united, so that an 
opening is left partially or wholly through it to the 
dentine ; besides, these indentations afford lodgment 
to foreign substances, which may be forced into them 
in the process of mastication, and there retained till 
becoming vitiated, they produce decay. 

Examine carefully the extent and the nature of 
the decay, and the form of the cavity, which, of 
course, greatly varies. In some cases the cavity is 
found with a small diameter and a comparatively 
great depth, the diameter at the orifice being the same 
as within ; in others, with a diameter larger at the 
orifice, as occurs in cases in which a considerable por- 
tion of the enamel at the depressions on the crown is 
imperfect. In the majority of instances, however, the 
diameter of the cavity is much larger within than at 
the orifice. Sometimes the decay is found to burrow 
directly beneath the enamel more rapidly than in any 
other direction, as where there is an imperfect union 
between the enamel and the dentine. In other in- 
stances, the cavity seems to expand uniformly as it 
extends into the tooth. 



220 CLASSIFICATION OF DECAYED CAVITIES. 

The manner of opening and preparing the cavity 
for filling will depend somewhat on the form given 
to it by the decay. If it is larger at the orifice than 
within, there will be little or no cutting of the cav- 
ity about the orifice necessary, except to make it 
even and smooth ; and its preparation will consist in 
an entire removal of the decay, and such shaping 
of the interior as will insure retention of the filling. 
This may be effected either by enlarging the cavity 
within, till its walls are parallel with each other, or, 
if these are left converging, by forming pits or grooves 
upon them at proper points. Converging walls pre- 
sent one or two advantages, which will be hereafter 
considered. Usually, where the decay has formed a 
cavity of nearly uniform diameter from the orifice to 
the bottom, about 8,11 the preparation for filling so far 
as the interior of the cavity is concerned that is 
requisite, is a thorough removal of the decay. In cases 
in which the decay burrows under the enamel, the 
projecting portions are to be cut down, either with 
a bur drill or, what is generally better, a heavy cut- 
ting instrument. In most instances it is best to cut 
away the enamel so far as the decay has extended 
beneath it, since it is difficult to make a perfect fill- 
ing under a projecting portion. In some cases, how- 
ever, where the enamel is thick and firm, it is admis- 
sible to leave a slight projection, so as to form a 
shallow groove. 



FILLING BY CLASSES AXD MODIFICATIONS. 221 

The walls of these cavities will be of various in- 
clinations. If they converge, pits or grooves may be 
required upon them for retaining-points, especially if 
the enamel is cut away at the orifice to the solid den- 
tine. If, however, the walls, or two opposite walls, 
are parallel, or but slightly divergent, these special 
retaining-points will not be requisite, except for the 
reception of the first pieces of gold. Small cavities 
of this class may be opened up and formed princi- 
pally with the bur and drill; and even in large cav- 
ities much of the work of opening, excavating, and 
forming may be done with the burs of the proper 
size and form, used with the engine. Thus the ori- 
fice of the small cavities would be round, while those 
of the large would be of various forms, determined by 
the direction of the decay, as round, square, triangu- 
lar, elliptical, parallelogramic. Cavities should not 
be formed much larger within than at their orifices, 
unless the filling can be consolidated so perfectly 
that it will not yield in the least under the greatest 
pressure of mastication ; for, if there is yielding in 
such cases under direct pressure, the filling being 
forced into a larger part of the cavity, withdraws 
from the walls, leaving an interval corresponding 
with the depression it has undergone ; and thus fluids 
would be admitted between the walls and the filling, 
and the purpose for which this was inserted would be 
entirely defeated. 



222 CLASSIFICATION OF DECAYED CAVITIES. 

Many operators ream the orifices of all the small 
and medium-sized cavities of this class, in order 
thereby to make a better finish to the border of the 
filling. Some operators prefer in all cases to remove 
the angle formed by the wall of the cavity and the 
surface of the tooth about the orifice, giving a rounded 
form to the border of the orifice, the object being to 
avoid fracturing or comminuting the edge of the en- 
amel or dentine about the cavity. All acute angles 
in -these cavities, especially if they extend to the ori- 
fice, should be obliterated, since it is impossible to fill 
them perfectly. This obliteration can be effected with 
a miniature chisel, or with the appropriate excavator, 
or, perhaps, better still, with the bur of the proper size 
and shape. 

After the formation of the cavity, the next particu- 
lar is, so to arrange as entirely to exclude moisture, 
whether from the saliva or from the breath. If pro- 
vision was not made at the beginning of the operation 
for the exclusion of moisture, it cannot now be longer 
delayed. As already intimated elsewhere, this is ac- 
complished by the use of the rubber dam. The gen- 
eral method of its application has been considered, yet 
a few suggestions in reference to it in an operation 
upon this class of cavities may be of value, especially 
to the beginner. 

The precise method of procedure at this point will 
be modified by the size of the mouth and the ability 



FILLING BY CLASSES AND MODIFICATIONS. 223 

or will of the patient to control it. For a cavity of 
this class, it will, in nearly all cases, where the mouth 
is favorable in the particulars just referred to, be quite 
sufficient to embrace with the rubber only the tooth to 
be operated upon, and this whether it be in the supe- 
rior or inferior jaw. 

If the tooth in question stands in firm contact with 
its neighbors, passing the rubber between the teeth may 
be quite unnecessary, but let it be drawn over the crown 
and down or up, as the case may be, upon the buccal 
and lingual sides to the margin of the gum, then 
place on the clamp, which will hold all in position. 

This properly done, all moisture will be effectually 
excluded; success in this, however, depends somewhat 
on the accurate adaptation of the clamp to the tooth. 
If the rubber can be readily passed between this and 
either or both of the contiguous teeth, it is well to do 
so, thus making the work more secure, if the clamp 
should be defective in adaptation. When the mouth 
is small, or not properly controlled, greater precaution 
will be requisite; in such cases the rubber should 
always be passed between the teeth, and in some in- 
stances over one or two neighboring teeth, in order 
that the operation may not be embarrassed by en- 
croachment of the rubber. But in no case should it 
be placed upon more teeth than are necessary to meet 
the demands of the case. The free border of the 
rubber should now have the elastic bands applied, so 



224 CLASSIFICATION OF DECAYED CAVITIES. 

that the utmost freedom of approach may be made 
to the point of operation. The cavity should be 
thoroughly dried with bibulous paper and the warm- 
air blowpipe; when a minute examination of the 
cavity, at every point and in every particular, should 
be made, and any imperfections remedied. And 
now, with the automatic saliva extractor in place 
and operating, the work of introducing the filling may 
proceed. 

In some small simple cavities of this class, in the 
upper teeth, with conditions favorable, and but a short 
time required for introducing the filling, the following 
arrangement may serve the purpose : Wipe dry the 
mucous membrane about the mouth of the duct of 
Steno, lay directly upon this a piece of heavy blot- 
ting-paper, or a roll of bibulous paper; then take a 
napkin folded cornerwise, place the end of it upon 
the paper between the cheek and the gum, passing it 
back of the tooth to be operated upon along the pal- 
atal surfaces of the teeth and the gums to the anterior 
part of the mouth, and letting a fold of it extend 
down from this and out over the inferior front teeth 
and the lip, so as to protect the tooth from the breath, 
and catch any fragments of gold that may drop from 
the instrument. The napkin and paper, thus ar- 
ranged, are to be kept in their place by the fingers 
of the left hand of the operator, and if the mouth of 
the duct is kept closed by the paper a complete ex- 



FILLING BY CLASSES AND MODIFICATIONS. 225 

elusion of moisture is secured, so far as that source 
is concerned. In some cases, pressure of the fingers 
on the napkin over the duct is necessary, in others 
the paper adheres to the mucous membrane and effec- 
tually prevents the egress of saliva. The cavity should 
now be dried by the method heretofore described, and 
it is ready for the filling. 

In the absence of the automatic saliva extractor, 
the saliva pump, represented in Fig. 88, will serve a 



Fig. 




valuable purpose, though it does not completely fulfil 
the requirements. 

An instrument invented by Dr. W. H. Dibble, 
called " Dibble's Saliva Pump," performs the work of 
both the saliva pump and tongue-holder. As a saliva 
pump it is much superior to the instrument represented 
in Fig. 88, which is in common use. 

It is operated by the patient, and removes the saliva 
immediately after it enters the mouth, and may be in 
constant action without the slightest interruption of 
the operation of filling; the saliva passes into a res- 
ervoir and is perfectly inclosed till the operation, how- 
ever protracted, is completed. 

15 



226 



CLASSIFICATION OF DECAYED CAVITIES. 




That part of the instru- 
ment designed to hold the 
tongue and the buccal sur- 
face from the tooth to be 
operated upon, and to hold 
the jaws apart, is of a very 
excellent forim and ac- 
complishes its work well. 
It is in three parts, one 
adapted to each side of the 
mouth — in these the saliva 
is taken up by the instru- 
ment opposite the lingual 
surface of the second in- 
ferior molar— and one for 
the front, with a compres- 
sor passing on to the 
tongue, and holding it firm- 
ly down, and the pump- 
tube takes the saliva from 
the immediate vicinity of 
the sublingual ducts. 

This latter part of the 
instrument is the device of 
Dr. B. F. Arrington. The 
instrument is well repre- 
sented in Fig. 89. That 
part of this instrument de- 
signed to hold down the 



FILLING BY CLASSES AND MODIFICATIONS. 227 

tongue is rendered unnecessary by the use of the rub- 
ber dam. 

It is often the case that the finger is too short to 
reach a desired point to hold down a napkin or paper, 
or hold away the soft parts, or is so large as to fill 
the space inconveniently, obstructing the view of the 
operation. To overcome both of these difficulties an 

Fig. 90. 




extension thimble is used ; it may be made of silver 
or rubber, though better of the former. In addition to 
the uses mentioned, it may, by having a fine steel 
point, be made to serve as a holder to aid in introduc- 
ing fillings. (Fig. 90.) 

Filling with Foil. — If non-cohesive gold is employed 
it should be formed into blocks, by cutting from four to 
eight thicknesses into strips one fourth wider than the 
cavity is deep, and rolling them on a broach, suitable 
for the purpose, into cylindrical blocks corresponding 
in size with the cavity to be filled, and varying not 
only in size, but in form and density. The blocks 
first to be introduced should be largest, followed bv 



228 CLASSIFICATION OF DECAYED CAVITIES. 

those diminishing in size, the last portions being small, 
•dense, conical rolls. Where there is an inward or 
outward inclination of the walls of the cavity, the first 
blocks should be cone-shaped. For introducing the 
blocks, the plugging pliers will be required. The first 
block is taken up with this instrument and placed 
against the posterior wall of the cavity, with one end 
on the bottom and the other protruding from the orifice, 
and there compressed firmly to its place with the ap- 
propriate condensing instrument ; and, unless there is 
some special retaining space, it may be necessary to 
hold it in its position with a second instrument, till 
the next portion is added. As the successive blocks 
are introduced, each is to be thoroughly consolidated, 
so as to be immovable. The filling is to proceed from 
the posterior wall to the centre. After the cavity has 
thus been filled to the centre, commence in the same 
manner at the anterior wall, filling from thence toward 
the centre, and condensing the last blocks by forcing 
in at their side a small sharp-pointed instrument ; the 
final portion introduced will be the small, dense, con- 
ical roll already mentioned. The gold being all intro- 
duced, a smooth-pointed instrument or burnisher con- 
denses the projecting portion of the filling till it is 
perfectly solid, when it is finished with a file, stone 
and burnisher in the manner already described. The 
particular shape of the surface of the filling will be 
suggested by the form of the antagonizing tooth. Usu- 



FILLING BY CLASSES AND MODIFICATIONS. 229 

ally the surface of these fillings should be slightly 
concave ; in some cases the occlusion of the teeth is 
such as to require very considerable concavity ; this, 
however, should only be sufficient to accommodate the 
closure of the teeth. 

For dressing down, the burs, corundum cones, Scotch 
stone and buff cones used with the engine, represented 
by Figs. 28 and 29, will serve the purpose most fully. 

Cohesive Foil. — For filling these cavities with cohe- 
sive foil, definite retaining-points should be formed in 
them, or the bottom of the cavity, of such a form as to 
retain firmly in position the first pieces of gold intro- 
duced. The gold, prepared in the manner already 
described, is taken up with a serrate-pointed plugger 
or plugging pliers, introduced into the retaining-point 
or points, and there fixed ; it is then built across from 
one to the other, and over the floor of the cavity till 
this is completely covered, and then up from the bottom 
to the orifice. When a portion of gold is taken on the 
point of the instrument, the precise spot at which to 
deposit it should be selected, and there it should be 
placed, and, by the first pressure of the instrument, 
fixed immovably ; a few subsequent strokes of the in- 
strument, near the first point of attachment, will be 
required. These strokes should be close, because if 
the instrument is lifted up and pressed upon the piece 
at a distance from the first point of contact, the attach- 
ment is liable to be broken. The character of the gold, 



230 CLASSIFICATION OF DECAYED CAVITIES. 

and the condition of the receiving surface will govern 
to some extent the precise method of manipulation. 
Very much depends upon keeping the surface in a 
good condition for the reception of the gold to be added. 
The best receiving surface is obtained by having the 
condensing instrument sharp and in good condition, 
and then in using it, let there be a little space between 
its impressions — the surface not stamped completely 
over by the condensing instrument. In constructing 
the filling, we consider it preferable to keep it built up 
a little higher all around next the walls than at the 
centre, for the reason that a more complete adaptation 
of the gold can thus be made than by any other plan. 
Some, however, advocate the opposite practice ; that 
is, of keeping the filling higher in the centre than at 
the walls, and thus forming an angular space into 
which to crowd the gold ; because the gold is thus kept 
in more thorough contact with the walls of the cavity ; 
and it is objected that, to add and consolidate the gold 
to the centre, while the edges are left higher, tends 
to draw them from the walls. This objection, however, 
has no force, if the gold is thoroughly consolidated as 
it is introduced. 

The cavity is thus filled up, consolidated, and fin- 
ished in the usual manner. In adding the last por- 
tions of gold, great care should be taken to make a 
perfect border to the filling. Crystal gold may be very 
advantageously used as a foundation for cohesive foil 



FILLING BY CLASSES AND MODIFICATIONS. 231 

fillings, as it will retain its position perfectly in a cav- 
ity, where foil will not. 

Crystal Gold. — The method of filling this class of 
cavities with crystal gold is very simple. The mate- 
rial should be annealed just before its use, and then 
cut or broken into blocks corresponding with the size 
of the cavity to be filled ; they may be used as large 
as will freely enter the cavity ; many small pieces 
will be required to fill up interstices or angles. The 
filling may be commenced at the bottom of the cavity, 
and built up from that to the orifice, the same plan 
being followed in adapting it to the walls as with co- 
hesive foil, the pieces being passed into the cavity 
with either the plugging pliers or a condensing in- 
strument. Each piece should be well consolidated 
before another is added. For condensing the filling 
next to the walls, a small wedge-shaped instrument is 
valuable. In all cases where there is a divergence of 
the anterior wall, care is required to make an efficient 
filling ; and too much care cannot be exercised in per- 
fecting the filling round the border of the cavity. 
In condensing cohesive foil or crystal gold, the force 
may be applied as nearly as practicable in a line with 
the axis of the tooth ; this is always preferable to 
lateral pressure. 

1st Mod. — Extension of decay along one or more 
of the crown fissures. — In a case of this kind, the 
central cavity is first to be opened and excavated, 



232 CLASSIFICATION OF DECAYED CAVITIES. 

according to the principles already announced. Decay 
in the fissures is in some cases an extension of the 
central decay, and at the point of its termination 
there will be found an acute angle ; but in others, it 
will be the effect of an equal attack all along the 
fissure, or of an extension from some other point 
than the central cavity. This modification of decay 
may terminate either in an acute angle or in an ex- 
pansion. 

These decayed fissures should be opened up by cut- 
ting away any projecting portion of enamel, and the 
cavities formed with a small chisel-shaped instrument, 
beginning at the juncture of the fissure with the main 
cavity, and cutting down to the bottom of the^ decay 
in the manner of a mortise, thus cutting out the en- 
tire fissure and the acute angle at its termination- — 
the latter is an important consideration. In case 
there is a very considerable expansion of decay at 
the termination of the fissure, the bur drill may be 
introduced into it, and the rest of the fissure cut out,, 
as the form of the cavity may indicate. In exca- 
vating and forming these fissures, the burs made for 
the purpose (shown in Fig. 22), and used with the 
engine, give greater facility and rapidity of execution 
than by the method just described, and with care,, 
equally as definite results. 

If blocks are used to fill these cavities, they should 
be set in and compressed against the end of the fis- 



FILLING BY CLASSES AND MODIFICATIONS. 233 

sure, protruding from it sufficiently to admit of a 
proper finish ; and block after block added, till the 
fissure is filled to the main cavity. Where there 
are two or three of these decayed fissures in one 
tooth, it may be quite as much as can be done at 
one sitting to fill them, the main cavity being left 
for another time. In such cases, the filling introduced 
at the first sitting should then be consolidated and 
burnished, so that it may not absorb moisture while 
the main cavity is filled, as already described. Much 
care should be exercised to prevent the gold from 
overlapping the enamel at the sides of these fissures. 
In filling this modification with crystal gold or an- 
nealed foil, it is better to begin at the bottom of the 
cavity and build up to the orifice, first completing 
the fissure, as we have already described, and after- 
ward the main cavity. 

2d Mod.-— Two cavities on the same crown in close 
proximity. — The thickness of the portion of tooth in- 
tervening between two cavities on the grinding sur- 
face of the same crown is determined by the location 
and extent of the decay and by the form of the 
cavities ; and these two conditions will suggest the 
method of operation. If this intervening portion is 
thin throughout, and devoid of vitality, it should be 
cut away, and the two cavities formed into one ; but 
if it is thick within, though it may be thin at the 
surface, the cavities should be filled separately. In 



234 CLASSIFICATION OF DECAYED CAVITIES. 

some cases it is proper to leave a part of it standing, 
as a sort of ridge between the cavities, though not as 
a definite partition ; in which case the filling would be 
commenced as in two cavities, and finished as in one. 
In no case, however, when the tooth is living, should 
this intervening portion remain, if its vitality is gone. 
The details of the process of filling crown cavities 
have already been indicated. 

Second Class. — Buccal and palatal cavities of 
the molars and bicuspids, and labial and palatal 
cavities of the cuspids and incisors. — In the mo- 
lars, this class of decay begins either at the margin of 
the gum, in the form of a transverse groove, or along 
the vertical depression on the buccal surface of the 
tooth, or at its termination. These groove-like decays, 
extending along the side of the tooth at or near the 
margin of the gum, are ordinarily not very deep ; but 
they burrow considerably under the enamel, particu- 
larly at the side next the grinding surface. In prepar- 
ing these cavities, the projecting portion of the enamel 
must be mostly cut away, leaving them but slightly 
larger within than at the orifice. These grooves, at 
their ends, are shallow ; but in their preparation for 
filling, they should be cut as deep at the ends as else- 
where, and deeper, when the main part of the cavity 
is comparatively shallow. Much difficulty is often 
experienced in protecting these cavities from moisture 
while being filled. The rubber dam, when well ap- 



FILLING BY CLASSES AND MODIFICATIONS. 235 

plied, accomplishes the object better than any other 
appliance ; it is in such cases invaluable. 

The method of introducing gold in the form of 
blocks into these cavities, is to set in the first block at 
the posterior part of the cavity, and consolidate it, and 
so one block after another till the cavity is nearly full ; 
and then proceed in like manner with the anterior end, 
back toward the middle, the blocks, of course, being 
permitted to protrude sufficiently for the purposes of a 
finish. For filling with crystal gold or cohesive foil, 
the method is, to form pits at the end of the groove, 
into which the gold is consolidated, and built across 
from one to the other, and then up from the bottom to 
the orifice, when it is finished as usual. Care is re- 
quisite to prevent the gold from overlapping the tooth 
outside of the cavity. Any projection of the filling, 
especially beyond the margin of the cervical wall of 
the cavity, is very objectionable ; it would afford a 
lodgment for extraneous substances, the tendency of 
which is to produce irritation and decay. 

Cavities of this class, which are formed in the de- 
pressions of the buccal portions of the teeth, are more 
easily filled. Often a simple round cavity is formed 
at the coronal termination of this depression, which 
may be entirely prepared with a bur drill. The 
method of filling these cavities will be readily inferred 
from the remarks before made. If, however, the decay 
extends along the depressions, making a groove-like 



236 CLASSIFICATION OF DECAYED CAVITIES. 

cavity, this should be filled by commencing the intro- 
duction of the gold at that part of the cavity next the 
gum. 

1st Mod. — Decay at or near the neck of the tooth, 
and partially or wholly overlapped by the free border 
of the gum. — In this modification the gum is an ob- 
stacle to the various steps in the process of filling. It 
is liable to be wounded and to bleed at every touch ; 
it exudes mucus constantly ; and it conducts saliva to 
the part with great facility. To obviate these difficul- 
ties, the gum must be removed somewhat from the 
cavity before the filling is practicable. This removal 
of the free margin of the gum may be made either by 
cutting away, or by pressing away with pledgets of 
cotton or other appropriate substance placed in the 
cavity and projecting from it, so as to make pressure 
upon and absorption of, to a sufficient extent, the free 
margin of the gum, which will usually be accomplished 
in a day or two. The former method, however, accom- 
plishes the object at once : some good hemostatic, as 
creasote and tannin, or better, persulphate of iron, is 
all that is then necessary to render the filling imme- 
diately practicable. By means of this application the 
exudation is checked, — which, where there is much 
mucus eliminated, is an important item, — and also such 
a surface is given to the part that it will not so readily 
conduct the saliva. It is perhaps preferable in many 
cases to cut away this free margin, so that it shall not 



FILLING BY CLASSES AND MODIFICATIONS. 237 

be in contact with the filling after the operation is 
completed. In nearly all such cases, by the proper 
application of the rubber dam with a perfectly adapted 
clamp, the whole difficulty will be overcome. 

After this preparation, the cavity is formed and 
filled as usual. 

In filling cavities of the buccal portions of the third 
molars, peculiar difficulties are encountered. The de- 
cay is frequently found two-thirds covered by the gum ; 
the muscles of the cheek, thick and rigid, lie close 
against the side of the tooth ; and, in most cases of this 
kind, the view, at best, is but partial. To meet this 
difficulty, a clamp with a broad flauge upon its outer 
blade is required for holding the soft parts away, and 
the rubber dam in its proper position. 

In nearly all such cases the reflector should be used 
to concentrate light upon the locality of the operation ; 
without this, the view into these cavities is much ob- 
scured. 

Third Class. — Anterior proximate cavities of 
the molars and bicuspids. — This class of cavities in 
teeth with short, broad crowns, takes place at their 
necks; but in those with long crowns, and with a diam- 
eter less at the neck than at the masticating surface, it 
begins at some distance from the neck, toward the crown 
surface, or at the first point of contact of the crowns. 
In almost all cases of proximate fillings separation of 
the teeth is required ; the method and extent of this 



238 CLASSIFICATION OF DECAYED CAVITIES. 

will be determined by circumstances. If all the neigh- 
boring teeth stand in contact, it cannot be easily ac- 
complished by pressure ; in this respect, however, there 
will be found a great variety ; but if a tooth has been 
extracted in the vicinity, or there are natural spaces 
between the others, it can be, either in whole or in part. 
When, however, the teeth stand close together, they 
must in such case be separated chiefly with the chisel 
and file. If but one is decayed, the cutting should be 
exclusively from that. If two are alike affected on 
their proximate surfaces, it should be mostly from the 
posterior surface of the anterior tooth. In regard to 
the form of the separation effected by cutting, the gen- 
eral practice formerly was to cut down the whole prox- 
imate side of the affected tooth, making between it and 
the adjoining one a V-shaped space, sufficient in extent 
to admit of free manipulation in all parts of the opera- 
tion of filling. By thus cutting the teeth, the form is 
marred, and often to great disadvantage in use, as by 
it the masticating surface is lessened, and food being 
crowded into such a space, produces very unpleasant 
pressure. In order to preserve the form and the 
greatest amount of masticating surface to the tooth, a 
preferable method is to cut down from the masticating 
surface to the cavity of decay, leaving the lingual and 
buccal sides of the tooth untouched, except, perhaps, a 
little dressing that may be rendered necessary by the 
thinness and roughness of the margins. This cutting 



FILLING BY CLASSES AND MODIFICATIONS. 239 

should extend about as far toward the centre of the 
tooth as the decay has penetrated, and be nearly as 
wide as the extent of the decay across the tooth ; it 
should be of dovetail form, or that part of the opening 
next to the centre of the crown slightly wider than at 
the anterior part. This form may very readily be 
given by the properly-formed excavators, or more rap- 
idly, and quite as well, with the fissure burs and engine. 
Care should be exercised in this particular, lest the 
lateral walls of the cavity be weakened by this cutting; 
and in doubtful cases, rather than incur such risk, it 
is better to avoid making the expansion altogether, 
and rely upon other modes of anchorage for the filling. 
The attachment of the filling may be made by prop- 
erly located pits and grooves. In making these, two 
points should be guarded, viz., weakening the walls 
of the cavity, and impingement upon the pulp. Care, 
good judgment and experience are necessary to most 
fully meet these requirements. When it is necessary 
to cut from the whole proximate surface, there should 
be no shoulder or projection left at the neck of the 
tooth, but the cut surface should be plain from the 
crown to its termination at or near the neck. The 
space, of whatever form it may be, should be large 
enough to enable the operator to manipulate with facil- 
ity, and to see as directly as possible into the cavity. 

Cavities of this class are various in form ; and they 
require much skill in their excavation and formation . 



240 CLASSIFICATION OF DECAYED CAVITIES. 

Special care is to be exercised not to leave any portion 
of decay in them. By a fatal oversight, decayed den- 
tine is often permitted to remain on that side next to 
the neck of the tooth ; and fillings that in other respects 
are good, are very deficient here— so deficient, indeed, 
that a sharp instrument will readily penetrate the soft- 
ened dentine above them, or even pass between the 
filling and the wall of the cavity. The removal of the 
decay from the cervical walls of all proximate cavities 
is an important particular, neglect of which occasions 
many failures. This class of cavities at this point 
should be most thoroughly filled ; for it is more vul- 
nerable than any other, on account of the facility with 
which foreign substances are here lodged and retained. 

In the formation of these cavities, the cervical wall 
should be made to incline slightly outward, and the 
lateral walls, if the tooth will bear the loss, made at 
least parallel with each other ; but if that would im- 
pair its strength, grooves or pi'ts may be made upon 
them for this purpose .at proper points. When these 
cavities are large, the dentine is usually all decayed 
in that part of the cavity next to the masticating 
surface of the tooth, leaving only the enamel, which 
by the mode of separating or opening, already de- 
scribed, would be cut away. 

The rubber dam being properly adjusted, the cavity 
is ready for the filling, which is introduced, if in 
blocks, as before detailed, beginning with the cervi- 



FILLING BY CLASSES AND MODIFICATIONS. 241 

cal wall. The caution may here again be urged, not 
to let the gold to overlap the tooth, particularly at the 
cervical wall. In filling with crystal gold or cohe- 
sive foil, special retaining spaces will be required in 
this wall, two being generally sufficient, one toward 
the outer and the other toward the inner lateral wall, 
on both of which grooves may be made, if the walls 
are thick enough to admit of it. If, however, these 
walls are not parallel, and will not admit of grooves, 
the crown and the cervical walls should be so shaped 
as to retain the filling. But in some cases the at- 
tachment of the filling is made entirely at the cer- 
vical wall ; and best by means of three pits, made 
with the square-pointed drill at different angles, and 
in such directions as not to interfere with the pulp. 
This kind of attachment will serve only for cohesive 
gold, which is to be very thoroughly consolidated 
into the pits, making little projections, which are so 
many anchors for fastening the filling, and built very 
firmly across from one to the other. 

2d Mod. — Decay involving a portion of the masti- 
cating surface. — There are two methods of filling this 
modification. One is, to cut down the tooth or the 
projecting angles, and make a plain, oblique border 
to the cavity by the V-shaped separation already re- 
ferred to, and then filled up flush with this border. 
The filling will thus exhibit a single, uniform surface, 
at a considerable angle with the axis of the tooth. 

16 



242 CLASSIFICATION OF DECAYED CAVITIES. 

When a portion of the crown breaks down in con- 
sequence of proximate decay, it is toward the centre 
of the tooth ; usually the inner and outer corners re- 
main. If these projections are feeble and liable to 
be broken away, they should be cut down and the 
cavity filled as before described. If, however, they 
are firm, they should remain, and the cavity, prop- 
erly formed, may be filled so as to restore the tooth's 
original form, which in the molars and bicuspids 
should be accomplished as nearly as possible, in order 
that the function of mastication should be perfectly 
preserved. By properly directed effort, the crowns 
of the teeth can in almost all cases, even where the 
walls are broken away, be well restored. Non-cohe- 
sive foil is not adaptable to this kind of filling, as it 
cannot be built in so as to withstand the pressure of 
mastication. In no case should a proximate filling be 
left in contact with the adjoining tooth ; with another 
filling it may. 

Fourth Class. — Proximate cavities of the in- 
cisors and cuspid ati. — If the teeth are not in a 
crowded condition, and the file is not required by the 
extent of the decay, separation may be made by pres- 
sure; but if the cavity is large, and the walls are thin 
and friable, cut with a thin chisel, or better with the 
diamond disk, till a good border is obtained about the 
cavity. Much has been said as to the form of these 
separations, some recommend that they be larger at the 






FILLING BY CLASSES AND MODIFICATIONS. 243 

palatine part than at the labial ; others, that they be 
larger at the points than at the necks of the teeth ; 
some, that a shoulder be left at the necks ; and others, 
that there be no shoulder at all. In making these 
separations, however, the operator must be governed, 
somewhat by circumstances, no general rule being ap- 
plicable to all cases. The form of the teeth and the 
extent of the decay, together with the character of 
the remaining enamel and dentine, will modify the 
form of the space between them. If the inner wall 
is thin or broken away, — and it is usually more fria- 
ble and' more broken than the labial wall,- — it should 
be cut off more than the outer ; in which case the pal- 
atine aspect of the separations will be the largest — as, 
indeed, some prefer to make it in all cases, perform- 
ing the remainder of the operation from the inside. 
Almost every operation upon these teeth will require 
attention and manipulation, in every step, from both 
the palatal and labial sides, in order to make secure 
every point. The precise mode of procedure must be 
determined by the case to which it is to be applied. 
The most direct approach is always to be employed 
when practicable. 

In some cases separation will be larger at the points 
of the teeth than elsewhere ; as, where there has been 
a partial fracture at the points. In cutting away to 
make the separation, no shoulder should be left at the 
neck of the tooth that is not to be protected by fill- 



244 CLASSIFICATION OF DECAYED CAVITIES. 

ing; any projection of that kind is always objection- 
able : foreign substances lodge upon and adhere to it, 
and, becoming vitiated, render it very liable to decay. 
The cutting should always extend entirely beyond the 
decay, but only far enough to make a perfectly plain 
border to all the cavity, and should terminate without 
any projection. It is highly important, in separating 
the anterior teeth to make as little alteration as pos- 
sible in their form. But the preservation of the tooth 
should not be jeopardized for the sake of maintaining 
wholly its natural form. The first consideration 
should be to obtain a space sufficient for the purposes 
'of a perfect operation ; the second, to have the walls 
and border of the cavity in such a condition that an 
efficient filling can be made ; and the form and beauty 
of the tooth should be scrupulously preserved and 
protected, so far as the above requirements will per- 
mit. 

The excavation of these cavities requires very deli- 
cate and skilful manipulation, since they are very 
readily injured by cutting too much or at a wrong 
point. All decayed and discolored portions must be 
entirely removed, as well for the appearance of the 
tooth as for the permanency of the operation ; after 
which the cavity is to be formed with great care. 
Toward the cutting edge of the tooth the dentine 
often has all been displaced by decay, leaving only 
the two plates of enamel joined at the edge, and thus 



FILLING BY CLASSES AND MODIFICATIONS. 245 

forming an acute angle, the obliteration of which is 
always attended with risk, unless great care is ex- 
ercised, and in many teeth it is wholly impractica- 
ble ; and still it is difficult perfectly to fill such an 
acute angle. The inclinations of the inner and the 
outer walls of the cavity when it is prepared, will de- 
pend on its size ; when it is small or medium they 
may be parallel, or, if necessary, slightly divergent 
inward ; but, when large, it is better not to cut much 
of the healthy dentine from them, lest they be thus 
weakened. Small grooves, however, are admissible on 
these walls, near the bottom of the cavity, when they 
incline to the centre, and are generally, in such case, 
to be preferred to pits. In the formation of grooves 
or pits for anchorages, the dentine should never be 
cut through to the enamel, but always dentine suffi- 
cient to protect the enamel should remain. More 
cutting is allowable on the cervical wall than else- 
where, as there is less danger here of weakening the 
tooth by excavation. In some instances the cavity 
upon the removal of the decay is of such extent and 
form as to admit of little or no excavation, except in 
the cervical wall; in this, then, the chief anchorage 
is to be made, and almost the entire reliance for the 
retention of the filling must be placed upon that part. 
Such a condition renders the use of cohesive gold a 
necessity, at least if a permanent result is to be at- 
tained. The best method of preparing such a cavity 



246 CLASSIFICATION OF DECAYED CAVITIES. 

is to make two or three little pits in it, at different 
angles, with a fine, square-pointed drill. Another 
method is to form two pits, and make a groove from 
one to the other. Some operators prepare these cavi- 
ties by making pits in each of the walls. This, 
however, is unnecessary, if the cervical wall is prop- 
erly prepared. 

In the application of the rubber dam for filling this 
class of cavities, three, four, or more teeth should gen- 
erally be included, in order that there shall be abso- 
lute security against moisture, and that the rubber 
shall be out of the way of the operation. The gold, 
prepared as already described, should then be intro- 
duced with a small plugger, serrated and somewhat 
flattened about a line above the point, so as to be 
freely used when introduced into the cavity. The 
gold is taken up on the point of this plugger, and 
condensed in the pits of the cervical wall, which, being 
completely filled, and the gold extending from one to 
the other, the foundation is ready for the remainder 
of the filling. 

Care is requisite in packing the gold into these cav- 
ities perfectly to adapt and adjust it to all points, so 
as to insure its thorough contact with every part of 
the interior. If the form of the tooth has been 
measurably retained, and the border of the cavity is 
even, the surface of the plug should, when finished, 
be slightly convex, or as nearly the original form of 



FILLING BY CLASSES AND MODIFICATIONS. 247 

the tooth as practicable. In introducing the filling 
reference should be had to this particular. Two-thirds 
of the cavity may be filled by introducing the gold 
upon and in the direction of this cervical wall, and 
the remaining portion filled from the point back to 
the preceding filling ; or, what is probably better, be- 
gin at the bottom and fill to the surface, and then 
finish in the usual manner. 

For filling these cavities with non-cohesive foil, the 
special retaining-points already described are not re- 
quired ; but the cervical wall of the cavity is slightly 
cut under, and the lateral walls so shaped as to se- 
cure the filling in place. These cavities are in some 
cases very difficult to fill with non-cohesive foil, 
whether in the form of blocks or otherwise, especially 
where they are large, with the walls inclined to the 
centre, and the tooth-bone friable. To force a wedge- 
shaped instrument into these fillings, for the pur- 
pose of condensing them, is not admissible, since there 
is thus great danger of breaking the walls of the 
cavity, and, in many cases, of moving the filling from 
its place. 

1st Mod. — The /palatal tvalls broken away. — Frac- 
tures of this kind assume different forms, sometimes 
triangular, extending from the border of the cavity 
toward the centre of the tooth, and terminating in an 
acute angle, and sometimes the border of the cavity is 
broken away irregularly, so as to form part of a circle. 



248 CLASSIFICATION OF DECAYED CAVITIES. 

When a triangular notch is broken out of the wall 
the operation of filling may be performed in one of 
two ways. If the portions of the wall remaining at 
each side of the fracture are thick and firm, they may 
be left, and the cavity filled so as to restore the form 
of both the proximate and the palatal surface of the 
tooth, the latter being thus restored with gold to the 
extent of the fracture or notch. If, however, the re- 
maining portions of the wall are frail, they should be 
cut away till a border is reached sufficiently firnr to 
sustain the filling. Such cutting will leave the notch 
of a circular form, and in many cases will remove 
almost the whole of the inner wall of the cavity. As 
the decay extends toward the centre of the tooth, 
owing to the concavity of its palatal surface, this 
wall becomes very thin and easily broken, thus ren- 
dering it necessary to cut it almost all away ; but in 
all cases the excavation should be such as to leave a 
definite wall, though it be but slight, all along that 
part of the cavity. In such a case, good retaining- 
points must be made in the cervical wall, since the 
permanency of the filling will depend almost entirely 
upon these. 

The surface of the filling, when finished, may be 
slightly convex from one lateral wall to the other ; the 
palatal portion of the surface, from the point of the 
tooth to its neck, will partake of the curvature of 
the border of the palatal wall; but the anterior por- 



FILLING BY CLASSES AND MODIFICATIONS. 219 

tion will be flush with and assume the outline of the 
anterior border of the wall. Much care is requisite 
to give these fillings a perfect finish on account of the 
irregularity of surface, this, in many instances, being 
both convex and concave. As a material for filling 
these cavities cohesive gold is much to be preferred. 
Indeed, in many of them it is impossible, with non- 
cohesive gold, to make a perfect filling, because they 
have no general embracing form. In such cases the 
filling should be introduced from the palatal side of 
the tooth. 

2d Mod. — The labial tvall of the cavity broken. — 
The fractures of this wall are of various forms, and 
in extent corresponding with the amount of decay and 
the friability of the enamel. There is sometimes the 
triangular notch, extending far toward the middle 
of the tooth; and sometimes there are two or three 
small notches; and, still in other cases, almost the 
whole of the wall will be broken away from the point 
to the neck of the tooth. When there is simply a 
notch in the enamel, it is important for the appear- 
ance of the tooth to fill it up; and when there is any 
prospect of success, the remaining portion of the wall 
being retained, the operation is to be performed as 
already described for the palatal wall. It will, how- 
ever, in many cases, be necessary to cut away part 
of the remaining portions of the wall, leaving the 
general form of the border somewhat circular, though 



250 CLASSIFICATION OF DECAYED CAVITIES. 

the notch form in some instances is not wholly ob- 
literated. 

In filling this kind of cavity it is desirable to re- 
store as much as possible the form of the tooth. The 
rilling should be built out from the border of the wall 
almost to a line with the tooth's original proportions, 
so that the whole surface of the filling will be convex; 
and it should be finished with special care, the Scotch 
stone, buff, or stipple finish being preferable for that 
part exposed to view. 

3d Mod. — The cavity extending almost to the point 
of the tooth, and terminating or running out at the 
surface. — In the preparation of this cavity that part 
next the point of the tooth should be cut in enough 
to form a definite wall there, and to give room for 
sufficient thickness and strength in that portion of 
the plug. Many operators attempt to fill this kind 
of cavity without such precaution, terminating that 
part of the plug in a thin edge. This method is very 
objectionable, for the thin edge will become more or 
less separated from the tooth, and foreign substances 
will be forced under it, and, becoming vitiated, induce 
decay. Indeed, a defect of this kind is a sure pre- 
cursor of the destruction of the filling. The intro- 
duction and finish of the filling in this kind of cavity 
are the same as first described for this class ; and the 
admonition may be repeated, that there be left no thin 



FILLING BY CLASSES AND MODIFICATIONS. 251 

overlappings of the filling that may become changed 
in position. 

4th Mod. — The cavity large, and the lateral walls 
thin and friable. — In this kind of cavity the dentine 
is almost entirely removed from the lateral walls, 
leaving little more than the enamel after the excava- 
tion of the decay. These walls will, of course, admit 
of no cutting for the purpose of giving them a more 
desirable form. The cervical wall must be shaped 
with special reference to a retention of the filling, to 
consolidate which the requisite pressure must be ap- 
plied almost exclusively toward this wall. It requires 
great care to condense the gold in cavities of this 
kind and adapt it to the lateral walls without frac- 
turing them ; various methods have been suggested 
to prevent such an accident. Pluggers with very fine 
points are recommended, as consolidating the gold 
with much less pressure than would be necessary 
with large-pointed instruments. But it has been 
maintained that a perfect adaptation of the gold to 
the inner parts of these walls is not important, pro- 
vided the adaptation at the border is perfect. It is 
certain, however, that a filling thus imperfectly 
adapted is not so good as though the gold were in 
contact with all points of the cavity; and besides, 
the liability of fracturing the wall is just as great in 
consolidating at the border as within. The walls may 
be sustained by enveloping the tooth to the borders 



252 CLASSIFICATION OF DECAYED CAVITIES. 

of the cavity with some material perfectly adaptable 
to it, and capable of resisting the force applied in the 
process of consolidation, as gutta-percha or plaster of 
Paris. If the former is employed, it should be soft- 
ened by warming, moulded upon the tooth, and then 
permitted to harden. The hardening may be facili- 
tated by throwing cold water on it from a syringe. 
It is then to be trimmed even with the border of the 
cavity, so as to admit the filling. If plaster of Paris 
is to be used, it should be of the best quality. Yet 
gutta-percha is to be preferred. In these fillings when 
the enamel is clear and translucent the gold w T ill be 
visible through it. To obviate this difficulty, and give 
strength to the frail walls, after the cavity is formed 
and thoroughly cleansed, it should be filled with oxy- 
phosphate of zinc. Care must be exercised in intro- 
ducing this to secure its perfect adaptation to every 
part of the cavity ; and after hardening has taken 
place excavate as may be requisite, leaving enough to 
constitute a good lining and support to the thin walls, 
and obscure the view of the gold. 

The natural color of the tooth may be in this way 
so well restored and maintained as to elude detection. 
At the border of the orifice the gold should come in 
contact with the dentine or enamel. In almost all 
cases of thin weak borders the gold should be built 
on and over them, so as to form a shield or protection 
against fracture or undue wear. All such overlapping 



FILLING BY CLASSES AND MODIFICATIONS. 253 

portions should be made so thick and firm as not to be 
displaced or moved. 

The loss of a portion of the cutting edge of the in- 
cisors by extensive decay is often met with. In all 
such cases when the dentine is of good structure, it 
is practicable to restore the lost part to a greater or 
less extent by building up with gold. In order to 
make successful operations in such cases several 
points must be regarded. The dentine and enamel 
should be of good structure; the cavity toward the 
neck of the tooth of such a form as to afford the best 
anchorage; this may consist of pits with grooves run- 
ning out from them. Teeth with thick, short crowns, 
present the best opportunity for such an operation ; in- 
deed, upon that class of incisors with long thin crowns, 
such an operation is not usually practicable, and gen- 
erally these teeth present such a contrast in color with 
the gold as to be quite objectionable. In the operation 
the manipulation must be such as to secure the most 
thorough welding of the portions of gold of which the 
filling is composed. With good attachments, gold 
well prepared and in good condition, and properly 
manipulated, the filling may be built up to any 
desired extent without danger of being either drawn 
out or broken down. The finish should be such as 
has already been described for fillings exposed to view. 

Fifth Class. — Posterior proximate cavities of 
the molars and bicuspids. — These are separated like 



254 CLASSIFICATION OF DECAYED CAVITIES. 

anterior proximate cavities, except that, ordinarily, to 
open them up more is to be cut from the tooth, on 
account of the greater difficulty of approaching, in- 
specting, and operating in the cavity. The same gen- 
eral principles are applicable to the opening of this 
class of cavities as to that of the third class, except 
that pressure for separating cannot be as frequently 
employed, since the cavity will not be as well exposed 
by this as by cutting, nor rendered so easy of ap- 
proach. Indeed, in operating on these cavities, the 
use of the mirror is often necessary, it being impos- 
sible to obtain a direct view into them after having 
cut away all that it is admissible to remove. This 
difficulty is almost wholly obviated by the method of 
working through the masticating surface of the tooth 
into the cavity of decay, as already described. The 
accessibility of these cavities will depend on circum- 
stances, such as the location of the tooth, its inclina- 
tion, the size of the mouth, the flexibility of the 
muscles, and the ability of the patient to open the 
mouth and keep it open. Generally in operating on 
these cavities for the removal of decay, for the forma- 
tion and the filling, curved instruments will be re- 
quired, but their curvature should not be greater 
than the necessity of the case demands. 

The cavity, during its preparation, must be fre- 
quently examined. Its general form, and the size, 
kind, and location of the retaining-points, will be the 



FILLING BY CLASSES AND MODIFICATIONS. 255 

same as in class third. The lateral walls, if the cav- 
ity is not too large, should be made parallel with each 
other ; the undercutting at the crown wall will be less 
than in anterior proximate cavities; and the cervical 
wall should have a slight inward inclination, — the re- 
verse of the same wall in anterior proximate cavities. 
In this latter there should be made, at different angles, 
pits for retaining-points — three, if the tooth is a molar, 
and two if a bicuspid. For making these pits, the 
engine right-angle hand-piece will be found applicable 
and convenient. 

Preparatory to introducing the filling, the same ap- 
pliances should be used to protect the cavity from 
moisture that have been described elsewhere. Much 
care should be exercised in introducing and securing 
the first portions of gold. The size, form, and loca- 
tion of the anchorage-points should be carefully noted, 
and into these the filling should be very perfectly in- 
troduced ; here the most thorough welding of the gold 
should be made, so that each piece when adjusted 
will be immovably fixed. The gold extending from 
one anchorage to another constitutes the foundation 
upon which the subsequent part of the filling is to 
be built. This may proceed uniformly from the cer- 
vical part of the cavity to the masticating surface of 
the crown, if, as is usual, the prepared cavity involves 
this surface. 

When the separation made between the teeth con- 



256 CLASSIFICATION OF DECAYED CAVITIES. 

stitutes a V-shaped space, the filling should have a 
single plain or slightly convex surface, which will be 
at a greater or less angle with the axis of the tooth, 
according to the greater or less amount cut away in 
the separation. Much care is requisite in order to 
make perfect work along the borders of the lateral 
walls of the cavity; these should be secured as the 
work progresses, and should in no case be left to 
receive attention after the body of the filling is intro- 
duced. 

When the lateral walls have been cut away, as was 
formerly the practice, it is much more difficult to re- 
store the crown to its original form and size than by 
the method now pursued — retaining the lateral walls 
and filling flush with them, and also protecting the 
edges by the filling. 

It is claimed that the difficulty of filling this class 
of cavities is much diminished by the use of the ma- 
trix. This appliance, in its present form, is the de- 
vice of Dr. Lewis Jack. He gives the following 
description of it and its use: "These little affairs are 
made of a variety of shapes, sizes and thicknesses. 
They are formed of slightly wedge-shaped pieces of 
steel, and are, as the cut designates, hollowed out at 
their thicker edge, which depression terminates at 
the thinner edge. At the part of the depression de- 
signed to give shape to the buccal edge of the filling, 
the cut is generally abrupt and deep; at the inner por- 



FILLING BY CLASSES AND MODIFICATIONS. 



257 



Fig. 91. 



tion it is more shallow and more inclined. It will be 
observed that the depression widens as it passes toward 
the inner edge to follow the usual form of proximate 
cavities. The lower and 
thin edge is rounded, to 
outline the curved mar- 
gin of the cervical walls, 
and to effect pressure 
upon either the gum or 
the appliances used to 
stop the escape of the 
mucus and blood from 
this tissue. 

"The plain parts of 
the face are file-cut, or 
coarsely draw-filed. The 
reverse side is, in most 
cases, plain and smooth, 
excepting a small por- 
tion at the thin edge, 

which is file-cut 

At each end a square cut 
is made, that the ends of 
the plier for adjusting 

them will fit into 

Quite a number of pairs 
are necessary to meet the requirements of the differ- 
ent cases, but for the ordinary- sized simple proximate 







258 CLASSIFICATION OF DECAYED CAVITIES. 

cavities, a dozen pairs, varying in width, in thickness, 
and in size of depression, are all that I have found 

necessary The character of the modifications 

that should be made in these will depend somewhat 
upon the desired end, since either a flat, contour, or 
excessively convex surface may be produced at the 
pleasure of the operator, or to suit the needs of the 
individual operation, by varying the form and depth 
of the depression." 

The ordinary forms of these appliances are repre- 
sented by Fig. 91. 

Some additional description of the matrices, and the 
method of using them, will be given in the Appendix, 
Sec. D. 

A piece of polished metal, of the proper thickness, 
may be placed back of the cavity against the adjoin- 
ing tooth, introducing the filling, and consolidating it 
firmly up to this piece of metal. The lost portion of 
the crown being thus restored, the metal is then re- 
moved and the filling dressed off and finished in the 
manner described heretofore. 

But when the opening is made by cutting in from 
the masticating surface, the entire opening made in 
the tooth, both by the decay and the operation, will 
be completely filled and the form of the tooth en- 
tirely restored; the filling will then present a proxi- 
mate and crown surface. When the teeth, molars and 
bicuspids, are decayed upon their contiguous sides, the 



FALLING BY CLASSES AND MODIFICATIONS. 259 

cavities in both may be prepared as already described; 
the j)roper separation and excavation having been 
made, both may be filled together, the gold extending 
across the space, and after being filled up flush with 
the masticating surfaces, the separation is effected by 
dividing the gold with a separating file. Thus, each 
cavity is completely filled, and there is always gold 
enough on the proximate parts to secure a complete 
finish. This method is not always practicable, as, for 
instance, when there is a large space, or when it is not 
desirable to fully restore the form of each tooth; but 
occasionally it may be used to advantage. The labor, 
tedium, and difficulty of manipulation are increased 
the farther back in the mouth the decay is situated. 
The modifications of this class are the same as those 
of the third class of cavities, and, except the second 
modification, are susceptible of the same methods of 
filling. 

Special Cases.-^- The first case that we shall con- 
sider here consists in a complication of proximate de- 
cay, with decay on the buccal or palatal portion of 
the tooth, thus undercutting one of the crown angles. 
Sometimes these decays are on both sides, in the form 
of transverse grooves, meeting at the corner of the 
tooth. In such cases, if the pendent crown-angle of 
the tooth is firm and strong, the cavities may be 
formed in the proper manner, and filled without in- 
terfering with the masticating portion of the tooth at 



260 CLASSIFICATION OF DECAYED CAVITIES, 

all; but if the pendent portion is friable it should be 
cut away, and the corner built up with gold. The 
method of forming the part to be filled will depend 
on the extent of the decay. When this is large, a 
greater number of retaining-points will be required 
than when it is. small, and these should be located at 
such parts as will make them most tenacious of the 
gold, and best conserve the strength of the tooth. The 
filling may be built up so as to restore the original 
form of the tooth, thus presenting three surfaces, the 
proximate, the buccal or palatal, and the masticatory ; 
or, it may be made with a single slightly convex sur- 
face, adapted and finished most completely at all its 
borders. This kind of filling can be made only with 
cohesive gold. 

The palatal portion of the crown broken away, leav- 
ing the outer portion standing — pulp not exposed. — -The 
tooth in such case is decayed away, so that the floor 
of solid dentine is near the margin of the gum, the 
labial third of the crown still standing. The decay 
having been all removed, four or five little pits should 
be made on this floor, as near its circumference as 
practicable, and a small groove may be cut from one 
of these pits to another all round near the edge of the 
floor. Then two little pits should be made at the 
base of the standing portion of the crown, if practi- 
cable, without interfering with the pulp, provided it is 
still living. The tooth thus prepared and properly 



FILLING BY CLASSES AND MODIFICATIONS. 261 

protected by the use of the rubber dam, the filling may 
proceed. 

For building up a crown of this kind only cohesive 
gold can be used; and this should be of the best 
preparation, and in the most perfect condition, since 
it is important that the different portions of the filling 
be most thoroughly united. The instruments em- 
ployed in the ojDeration should be of the best kind, 
and in the best condition, the serrate points being 
definite and sharp, though not too long; those with 
four, six, or eight points may be advantageously used 
for packing the gold. But care must be exercised lest 
these fine points be turned ; for, when that is the case, 
the instrument is liable to displace the portion of gold, 
and thus break up its first attachment during the 
process of consolidation, and, when this is broken, the 
piece of gold cannot again be made to adhere as per- 
fectly as before. 

With everything thus in readiness, the retaining- 
points are to be all filled, the gold extending from one 
to the other ; this is then to be built all over the bot- 
tom of the part to be restored, projecting a little beyond 
the periphery, and being perfectly consolidated there, 
and kept somewhat higher round the border than in 
the centre. The gold should be built up in this man- 
ner till the crown is large enough, after dressing, to 
give the desired size and form. In finishing up, the 
aim should be to restore as perfectly as possible the 



262 CLASSIFICATION OF DECAYED CAVITIES. 

lost form of the tooth. The adaptation of the gold 
to the standing portion of the crown should be most 
complete; imperfection in this respect impairs the 
appearance of the work, and jeopardizes the security 
of the operation. 

Occasionally the crown of a molar tooth is found 
"decayed off all round, almost to the margin of the gum, 
the pulp having previously receded so as not to be ex- 
posed. It is in such case desirable to restore the lost 
portion of the crown, and make a masticating surface 
such as shall antagonize properly with the teeth of the 
opposite jaw. This may be done by building it up 
with cohesive gold. Or a better method is to make a 
crown of gold or platinum plate, of the proper form,, 
and attach, as will be described in the chapter on arti- 
ficial crowns. In the preparation for the crown of 
gold foil, the edge should be dressed smooth and even 
all round the tooth ; then six or eight deep pits should 
be made at different angles on the base thus prepared ; 
and they should be bored with a drill larger than is 
commonly used for retaining-points. These pits may 
be slightly enlarged within. The method of building 
up the crown is just the same as that described for 
building up part of a crown, the pits being first filled,, 
then joined together, and the gold extended all over 
the part to be covered by the filling. In extending, 
the gold from one retaining-point to another, it is 
necessary to build up to a considerable thickness above 



FILLING BY CLASSES AXD MODIFICATIONS. 263 

the orifice of the pit. The portion of gold extending 
along on the tooth from the pit should be quite thick 
and firm, so as not to curl up from its position on the 
addition of subsequent portions. Every rjarticle of 
gold, indeed, should be so manipulated, that it will se- 
curely maintain its first position. The permanency of 
the operation will depend very much upon this ipre- 
caution. The gold should extend somewhat beyond 
the circumference of the tooth all around, in order to 
a thorough adaptation and finish. 

The foundation thus prepared, and kept free from 
moisture, the crown is easily built up by the ordinary 
method of packing the gold. Any desired shape can 
be given to this artificial crown ; but, of course, that 
which most nearly resembles the form of the natural 
crown is in all cases to be desired. The masticating 
surface of this gold crown is to be formed from the 
indications given by the antagonizing teeth. Such 
crowns will wear for years, and perform all the func- 
tions of the natural organs. Artificial crowns of this 
kind have been attached to the tooth, by screwing into 
the pits small pieces of gold wire at different angles, 
and then building up round and between them with 
the gold foil, on the principle already described, thus 
making these wires serve as so many anchors for fast- 
ening the work. The use of screws for securing fill- 
ings in these extreme cases was suggested, and perhaps 
occasionally used,, more than thirty years ago, by Dr. 



264 



CLASSIFICATION OF DECAYED CAVITIES. 



W. H. Dwindle. But about ten years ago their prac- 
ticability was more fully demonstrated by Dr. Mack, 
who devised a set of instruments by which small gold 
screws can be very readily introduced wherever they 
are required. These screws, as made by Dr. Mack, are 
screw-cut the entire length, except a small portion of 
the outer end, which is made flat and wedge-shaped ; 
upon this flattened part the screw-driver acts when the 
screw is introduced. 

Something additional in this direction seemed desi- 
rable, and to meet this want, Dr. E. Osmond, about ten 
years ago, made an improved screw, and constructed a 
set of instruments for introducing it. These are rep- 
resented in the following cut. 

Fig. 92. 



A a 




These screws are made of twenty-carat gold, an- 
nealed and split about half-way, once or twice, so as 
to form two or four arms. These are opened and 
turned down, as may be necessary after being inserted. 



FILLING BY CLASSES AND MODIFICATIONS. 265 

They are made of different sizes, to meet the require- 
ments of different cases, and the instruments are adap- 
ted to the different screws. The teeth represented in 
this cut show large converging cavities, in which, the 
screws are fixed, ready for the attachment of the fill- 
ing. 

It has been suggested that making barbs on the 
screws would give greater security to the filling than 
the plain screw, yet with Dr. Osmond's screws the ut- 
most security is attained. Of course cohesive gold is 
always to be used with this kind of anchorage. 

Security of attachment of these large fillings may 
in many cases be quite as well attained with the 
foil alone. But good tooth-structure and properly- 
located and well-formed anchorages are very impor- 
tant. 

Filling large cavities on the labial surfaces of the 
superior incisors. — These cavities are usually super- 
ficial, and frequently occupy a considerable part of 
the surface of the tooth, A method of filling them, 
somewhat novel, though not without merit, has been 
introduced to the notice of the profession by Dr. Volck, 
it having been first suggested to him, however, by Dr. 
Maynard. It consists in filling up the cavity princi- 
pally with a piece of enamel, as near the color of the 
tooth as possible. The cavity, when nearly round, 
should be formed with a wheel bur of the proper size ; 
and after having been thus reamed out, a slight under- 



266 CLASSIFICATION OF DECAYED CAVITIES. 

cutting should be made all round with an excavator. 
Then a piece of enamel being selected, it is dressed to 
a proper thickness, which should be slightly greater 
than the cavity's depth, and to a perfectly circular 
form, its size being such as to let it drop, with a little 
play, into the cavity, and the edge of it bevelled from 
without. For fastening this in the cavity, roll a strip 
of several thicknesses of gold foil round its edge, and 
add as much as can be forced in with it. Thus pre- 
pared, set it in place in the cavity, and then condense 
the gold down into the groove all round with a three- 
pointed plugger, more gold being added, if necessary, 
to fill the groove completely full. Afterwards, with 
the file, stone, or burnisher, dress off the whole to a 
proper level with the surrounding tooth, finishing very 
carefully with the burnisher. The unsightliness of a 
large gold filling on a front tooth is thus obviated, no 
metal except that composing the ring of attachment 
in the groove being exposed to view. It is a beauti- 
ful operation, and one whose successful accomplish- 
ment will require considerable constructive talent and 
skill. 

A better method of performing this operation, for 
many cases, at least, is by setting a porcelain filling or 
block in oxy-phosphate of zinc. The cavity should 
be prepared as usual, the borders neatly trimmed, 
and made as free as possible from irregularities. Se- 
lect a section of a porcelain tooth as near the color 



FILLING BY CLASSES AND MODIFICATIONS. .267 

and surface conformation of the tooth to be filled as 
possible ; then fit the piece to be supplied carefully, 
making it to conform to the cavity as accurately as 
possible ; it should be a little thinner than the depth 
of the cavity. The cavity now being secured against 
moisture, and made perfectly dry, oxy-phosphate of 
zinc, or some similar plastic material, should be pre- 
pared of such a consistence as to permit the accurate 
adjustment of the porcelain filling. This, after being 
put in place, should not be disturbed nor moistened 
till the cement is well set. It is better to cover the 
joint with wax or varnish, and let it remain a day or 
two, before attempting to dress or polish the porcelain ; 
if, however, the work has been perfectly done, nothing 
else will be required. Porcelain caps or cavity-stoppers 
are now made by manufacturers of teeth, to be used 
in these cases, and in the same way as above described. 
They are made in sufficient variety, in size, form, and 
color, to meet every case in which such an operation is 
admissible. Fig. 93 will give a correct idea of these 
stoppers as now prepared. 

There will be in almost every case more or less of 
fitting and adjusting before the stopper is finally set. 
Each variety is made with notches, slots, or grooves, 
in order that they may be firmly anchored by the 
cement in which they are set. 

The more accurate the fit of the cap or inlay, the 
more permanent will the operation be. If there is an 



268 CLASSIFICATION OF DECAYED CAVITIES. 

imperfect adaptation, the space between the cap and the 
margin of the cavity may be filled with gold. This 
may be done at once so soon as the cement of the sit- 
ting is sufficiently solidified, or this may be delayed 
until the cement is somewhat worn away. 

Fig, 93. 
Class A. 



Class B. 



IOOOOOO 

Class C. 

IOOOOOO* 

Class D. Class E. 



Qg 



An operation performed in this manner is prefer- 
able to a filling of gold for this class of cavities ; it is 
less apparent to the view ; indeed, when a proper se- 
lection has been made, and the adaptation is good, it 
will not be visible at all except under the closest ob- 
servation ; and usually the tooth will be as well pro- 
tected, and in many instances better, than by the com- 
mon method of filling. 



FILLING BY CLASSES AND MODIFICATIONS. 269 

The use of platinum and gold foil together, as sug- 
gested by Dr. Black, for filling these cavities, is better 
than gold, so far as appearance is concerned ; the strik- 
ing contrast between the color of gold alone and that 
of the tooth is materially relieved. 



CHAPTEE VIII. 



PATHOLOGICAL CONDITIONS. 



Hitheeto, in the consideration of the treatment of 
caries, the subject of the vitality and pathological 
conditions of the teeth has been intentionally omitted. 
It now remains to describe the diseased conditions to 
which the teeth are subject, and the treatment which 
these respective conditions indicate. This is an im- 
portant department of the practice, since upon skill in 
this, as well as upon the manner of performing the 
work, the success of the operation depends. 

Premising that our remarks on this branch of the 
subject are predicated on the fact admitted, that the 
teeth possess vitality, we proceed to consider the 
pathological conditions to which, in common with all 
vital tissues, they are liable. There is but one diseased 
condition of living dentine, anterior to decay, that 
presents any considerable difficulty in the ordinary 
operation of filling teeth, and that is, inflammation, 
or exalted sensibility. This condition was referred 
to in the remarks on the treatment of caries, as being 
one that most generally accompanies decay of the 
teeth. Whether or not this affection is real inflam- 
mation, is a point that has been considerably contro- 
verted ; and the assertion has been made that it is of no 



SENSITIVE DENTINE. 271 

consequence whether it is or not, provided we under- 
stand the true method of treating it. This, however, 
is not to be so readily conceded ; for the confession 
that we do not know what to call a thing, generally 
implies an ignorance of its character and phenomena. 
While the term inflammation conveys a more definite 
notion, the phrase exalted sensibility is very vague in 
meaning. That it is true inflammation, is the opinion 
of our best dental writers. 

The dentine is endowed with the functions of ab- 
sorption, nutrition, and secretion, modified somewhat 
by the peculiarity of the structure — characteristics 
that always imply a susceptibility of inflammation. 
In inflammation of the soft parts there are present 
various indications, — as pain, redness, swelling, and 
increased heat. But in dentine, on account of its pe- 
culiar structure, all these indications cannot be mani- 
fested; for instance, redness, since the red globules do 
not circulate through it; nor swelling, since the struc- 
ture is dense, devoid of mobility; nor perceptibly in- 
creased heat, since the circulation is of too low a 
grade. But one of the most definite indications of in- 
flammation, namely, exalted sensibility, is present here 
in a very marked degree; and there are various other 
circumstances that indicate this condition to be .real 
inflammation ; the same irritating causes that induce 
inflammation in the more highly organized parts, 
occasion it in the living dentine. This condition of 



272 PATHOLOGICAL CONDITIONS. 

the teeth is always affected by a general inflammatory 
diathesis, and their sensitiveness, when there is this 
general tendency to inflammation, is always increased, 
and local treatment in such cases will commonly be 
inefficient; a modification of such a condition of the 
system produces a corresponding change in the af- 
fected teeth ,, and those remedial agents which are 
employed in the topical treatment of inflammation 
elsewhere are successfully used in the treatment of 
inflamed dentine. From all these circumstances we 
infer that this affection of the teeth is a real inflam- 
mation. 

As has been already remarked, the only definite 
and direct indication of inflammation of the dentine 
is exalted sensibility, though this is not an imme- 
diate consequence of that condition, independent of 
external circumstances; for the pain resulting directly 
from inflammation in the soft j)arts is not experienced 
here by reason of the low grade of vitality and the 
feeble circulation. But the teeth in a state of inflam- 
mation will suffer pain when subjected to sudden 
variations of temperature, whether induced by the 
air, by fluids, or by contact with any hard substance ; 
and when subjected to the influence of agents that 
irritate the nerve-tissue anywhere, such as acids, some 
alkalies, salts, etc. In regard to degree, extent, and 
location, this affection exhibits a variety of manifes- 
tations; in degree from the most mild to the most in- 



SENSITIVE DENTINE. 273 

tense — sometimes fixed at a uniform degree of pain, 
and sometimes passing through the gamut of torture 
up to the most acute anguish. The character of the 
affection is modified by differences in the organic struc- 
ture of the teeth, those most vascular and most 
highly organized being most readily, and most exten- 
sively involved; and therefore the teeth of the young 
are generally more liable to it than those of the old. 
So, too, persons of a plethoric or a strumous habit, as 
well as those in a febrile condition, are peculiarly 
predisposed to this affection. Sometimes irritation 
or disturbance of other organs of the system sympa- 
thetically or secondarily induce inflammation of the 
dentine. Uterine irritation frequently does so, and 
hence, during pregnancy, or a protracted suppression 
of the catamenia, the teeth are very liable to be 
thus affected, and, if decayed, to become very sensi- 
tive. 

Inflammation of the dentine will sometimes be ex- 
hibited in various degrees in different teeth in the 
same mouth at one time. This is owing to differences 
in the organic structure of teeth developed at different 
periods of life, to differences of their location in the 
mouth, and to differences of exposure to those agen- 
cies which are apt to induce the condition. As to the 
extent of this inflammation, it may be confined to a 
thin lamina of bone immediately beneath the decom- 
posed portion, or may extend deep into the body of 

18 



274 PATHOLOGICAL CONDITIONS. 

the tooth, and, indeed, in some cases, pervade the den- 
tine of the entire crown. This latter extent, how- 
ever, is not likely to occur, unless there is a general 
predisposition; if it is produced by local causes, it 
will not, in general, penetrate very deeply into the 
dentine. Most commonly, the greatest sensitiveness is 
at the union of the dentine with the enamel, but, 
sometimes, it is confined to a small point within the 
cavity, either because of an increased susceptibility 
there, or because there has been a concentration of the 
irritating influences to that point — the former being 
jxrobably the more frequent. The greatest sensitive- 
ness, as already remarked, is generally at the surface 
of the dentine, because that is the termination of the 
nerve-fibrils which ramify the dentine, and wherever 
nerve-fibre terminates, there always we may look for 
exalted sensibility. Hence it is that decay of the teeth 
is often found to be more sensitive in its incipient 
stages than when it has become more advanced. 

Treatment of Inflamed Dentine. — There are several 
methods of treatment that may be employed to rem- 
edy this condition. In many cases, where time and 
circumstances will permit, a removal of all irritating 
agents from the affected parts will enable nature to 
effect a restoration to health. All decomposed den- 
tine is to be removed from the cavity, every exciting 
influence in it withdrawn or neutralized, and the 
cavity itself perfectly filled with some non-conducting 



TREATMENT OF SENSITIVE DENTINE. 275 

material, so as entirely to exclude all foreign sub- 
stances. So far as non-conduction of heat is con- 
cerned, there is, perhaps, nothing better than "Hill's 
stopping ;" or, in some cases, tin or gold may be used; 
but when either of these is employed for this treat- 
ment some non-conducting substance should be placed 
between the filling and the sensitive dentine. The 
length of time necessary for the restoration of the af- 
fected part, under this treatment, will be much varied 
by circumstances. The cases susceptible of this kind 
of treatment are those in which there is no constitu- 
tional predisposition, in which the vitality is strong, 
and the recuperative power vigorous. "When the tem- 
porary fillings are made of metals, the patient should 
be careful to protect them from sudden changes of 
temperature. For such fillings, in case they are re- 
quired but for a short time, a lock of cotton saturated 
with a solution of gutta-percha and chloroform may be 
used. 

But, in cases in which the vitality is low, the af- 
fection chronic, the exciting cause highly irritating, 
and the general diathesis inflammatory, nature, un- 
aided, will not effect a cure. In such circumstances, 
therapeutic treatment is indicated. The agents em- 
ployed in topical treatment may be divided into two 
classes: first, resolvents, or those which have for their 
object an entire restoration to health of the part af- 
fected ; and, second, escharotics, or those which have 



276 PATHOLOGICAL CONDITIONS. 

for their object the death of a portion or all of the 
diseased part. The former class of agents is of course 
preferable, when the object can be promptly accom- 
plished by their use, and especially preferable to those 
agents which endanger the vitality of the whole tooth. 
In very many cases in which topical applications are 
indicated, constitutional treatment is also required; 
and this should be of an antiphlogistic character. 
The immediately adjacent parts, too, as the gums, the 
mucous membrane, etc., should be carefully regarded. 
Indeed, treatment of the gums by counter-irritation, 
depletion, and various preparations, such as the con- 
ditions may indicate, will often be found prerequisite 
to a successful treatment of sensitive dentine by topi- 
cal applications. 

There are very few agents used simply as resolvents. 
The properties characteristic of this class of agents 
are tonic, stimulant, sedative, and astringent. Cap- 
sicum may fitly represent the stimulant; Peruvian 
bark and gum myrrh, the tonic; tannin the astrin- 
gent ; and opiates the sedative principle. Astringents, 
stimulants, and sedatives, all tend to counteract in- 
flammation. The agents of this class are not very ex- 
tensively used in the treatment of sensitive dentine, not 
because they are not ultimately efficient, but because 
their action is less vigorous than that of some other 
agents. When, however, time and circumstances 



TREATMENT OF SENSITIVE DENTINE. 277 

will permit, mild treatment, if efficient, is to be pre- 
ferred. 

But there are many cases in which, for want of time, 
something more rapid in its action is required. Of 
this character is the second class of therapeutic agents, 
namely, escharotics, or those which by their action de- 
stroy a portion of the tissue with which they come in 
contact. It may be well to notice, separately, the prep- 
arations commonly used for this purpose. 

Tannin, or Tannic Acid. — This is the active prin- 
ciple of vegetable astringents, and is found most abun- 
dant in nutgalls. It unites with albumen, fibrin, and 
gelatin, forming with them insoluble tannates. Its 
medicinal influence is almost necessarily topical, since 
the promptness of its action on albuminous substances, 
and the insolubility of its compounds with them, pre- 
vent its admission into the general circulation. The 
action of tannin on dentine has been already explained. 
Either its aqueous or its alcoholic solution may be em- 
ployed, the latter being the better and more convenient 
preparation. It is, however, recently used by solution 
in creosote and glycerin, which constitute a very valu- 
able preparation. Where tannin is applied to dentine, 
there is formed a tan n ate of albumen, which, being in- 
soluble, protects from irritation, and probably incites 
to healthy condition the living parts beneath it. 

Creosote, and Carbolic Acid. — Formerly, creosote 
was obtained by distillation of wood, and differed some- 



278 PATHOLOGICAL CONDITIONS. 

what from that in present use, which is prepared by 
distillation of coal tar. It dissolves freely in alcohol 
or ether, and sparingly in water ; its action may, 
therefore, be modified by dilution. Creosote produces 
its caustic effects by its affinity for albumen and gela- 
tin, with which it forms insoluble compounds ; and 
from its modus operandi, it is evident that the popu- 
lar opinion that it promotes decay of the teeth is an 
error. 

Nitrate of Silver. — This salt is a powerful caustic, 
whether applied to soft parts or to bony tissue. Its 
action is somewhat complex. Nitric acid is liberated 
by the decomposition of the salt when in contact with 
organic matter, and especially bone or dentine. Ni- 
trate of silver has a strong affinity for albumen, unit- 
ing with it without difficulty ; and the compound thus 
formed is soluble in nitric acid. When the nitrate is 
applied to the skin, the immediate result is a whitish 
mark caused by a union of the salt with the albumen 
of the cuticle ; but this soon turns black, by the re- 
duction of the salt and the liberation of the oxide of 
silver, when for each atom of this set free there is lib- 
erated an equivalent of nitric acid. There is here, 
then, an agent' that acts promptly on the gelatinous 
portion of the tooth, destroying its vitality to the ex- 
tent of the combination which takes place, and that, 
by the decomposition of part of the salt, and the con- 
sequent liberation of part of the acid, also acts with 



TREATMENT OF SENSITIVE DENTINE. 279 

energy on the calcareous portion. The compound 
formed by the nitrate with the organic constituents of 
the tooth, is insoluble except with a few substances, and 
therefore protects the subjacent parts ; and the pre- 
cipitation of the reduced oxide on the surface, it is, 
claimed, affords some additional protection. The in- 
solubility of the compound above mentioned prevents 
an absorption of the nitrate by the dentine, and renders 
its action necessarily superficial. When the nitrate is 
neutralized by a union with it of an equivalent of the 
constituents of the dentine, no further chemical action 
is possible. The compound formed by this union is 
soluble in a dilution of the nitrate ; and if this be ap- 
plied in too great a quantity, there may be a larger 
loss of substance than is desirable or at all necessary ; 
for as long as free nitrate remains in solution in the 
cavity, the insoluble compound is not precipitated, and 
the surface is therefore exposed to the continued ac- 
tion. It is preferable to employ the nitrate in the solid 
state, or, when this is not practicable, in a concentrated 
solution, and small quantity, rather than in a copious 
dilution and repeated application. 

From the observations already made, it is quite 
evident that no harm can result to the tooth from a 
proper application of this agent, beyond the portion of 
it immediately acted upon. The nitrate cannot be 
absorbed by dentine, but it stimulates the subjacent 
dentine to more healthy action ; though some main- 



280 PATHOLOGICAL CONDITIONS. 

tain that it is not as efficient in this respect as some 
proper chloride. It acts to a greater depth than tan- 
nin or creosote, but not so deep as chloride of zinc, nor 
with so much pain. Great care should be exercised 
that its contact be permitted no further than its action 
is desired. 

Chloride of Zinc. — This agent has been extensively 
used in the treatment of sensitive dentine, though 
much less now than formerly. It exerts an antiseptic 
and disinfectant, as well as an escharotic, influence. 
In its operation it decomposes ; the chlorine obtaining 
hydrogen by decomposition of water, hydrochloric acid 
is formed ; this unites with the calcareous elements, 
and breaks down the animal constituent as well. It is 
milder in solution than in solid, and less efficient and 
less painful. It is soluble in water, alcohol, ether, or 
chloroform. The ethereal and the chloroformal solu- 
tions are, in their action, least painful of all the forms 
in which this chloride is applied. The union of this 
agent with the gelatinous constituent of the tooth is 
also more prompt in solution than in solid. The ether 
and the chloroform may lessen the pain by their anaes- 
thetic influence. In the use of the chloride, or any 
other active caustic, it is important to bear in mind the 
exalted vitality which follows its application ; and the 
operation should be immediately performed. In the 
teeth of young persons, or those in which the animal 
constituents greatly predominate, the vitality will be 



TEEATMENT OF SENSITIVE DENTINE. 281 

more promptly aroused than in those of an opposite 
texture, and the change, too, will be greater. If the 
inflammation is confined to a thin lamina, it will be 
almost instantly allayed by the application of the chlo- 
ride, and the cavity may be excavated as though there 
had never been exalted sensibility in it ; but if the op- 
eration be delayed any considerable time, the tooth will 
often be found in a worse condition for excavating 
than before the application. The remarks on absorp- 
tion under the head of nitrate of silver apply with 
equal force here : there is not the least danger from 
this source-; indeed, there can be none, even when the 
chloride is applied to the soft parts. 

Ter chloride of Gold. — Of this preparation the ethe- 
rial solution only has been employed. This acts 
with great promptness on the dentine, forming an in- 
soluble compound with the gelatinous elements, and 
the chlorine performing its role upon the calcareous 
portion. On account of the promptness with which 
this agent operates, neither the pain nor the disturb- 
ance of the subjacent parts caused by it is great. This 
substance is very liable to decomposition. By expo- 
sure to air or light, the gold is precipitated in the 
metallic form. But protected from these, it may be 
preserved for a long time. This agent will not be 
absorbed by the dentine. 

Arsenious Acid. — The modus operandi of this agent 
is involved in obscurity. In regard to its topical ac- 



282 PATHOLOGICAL CONDITIONS. 

tion, Professor Bache says : " Arsenious acid, when it 
jDroduces the death of a part, does not act, strictly 
speaking, as an escharotic ; it destroys the vitality of 
the organized structure, and its decomposition is "the 
consequence. The true escharotic acts chemically, 
reducing a decomposition of the part to which it is 
applied, — a state incompatible with life." Pereira 
says : " Though employed as a caustic, yet the nature 
of its chemical influence on the animal tissue is un- 
known ; hence it is termed by some a dynamic caus- 
tic." Its escharotic power certainly bears no propor- 
tion to its devitalizing power ; but it is probable that it 
forms definite compounds with some of the constituents 
of living tissue; and if so, these compounds appear 
to be readily and rapidly decomposed, so that the 
acid becomes again free to attack, with similar results, 
the subjacent parts. The topical application of ar- 
senic is liable to be followed by constitutional effects. 

All dentists are aware of the fact that a tooth-pulp 
may be destroyed by arsenic, through a wall of con- 
siderable thickness. To accomplish this, the agent 
must in some way j>enetrate the substance of the 
dentine, and its vitality is destroyed so far as it is 
thus penetrated ; indeed, the vitality of the whole 
crown of the tooth, both dentine and pulp, is often 
destroyed by the use of this remedy, applied even to 
a small cavity. Exalted sensibility of dentine is sub- 
dued by this agent, more by devitalizing than through 



TREATMENT OF SENSITIVE DENTINE. 283 

its chemical energy. It is soluble in creosote and 
similar oils, and to a considerable extent in alcohol 
and water. It is absorbed much more rapidly when 
applied in solution than in solid ; and the more vas- 
cular the dentine, the more rapid and extensive will 
be the absorption ; and on this account there is great 
risk in applying it to the teeth of young persons, or 
to any teeth that are highly wanting in density ; in- 
deed, it will destroy the vitality of very dense teeth. 
The manner in which it passes into the dentine is not 
definitely understood. It is very certain, however, 
that in more highly organized parts it is carried 
through by the circulation, and also may be taken up 
by imbibition. In the latter of these ways it passes 
into the dentine. It is enough to know that there are 
well-defined cases of its specific effect on the constitu- 
tion, after having been applied to dentine, demonstrat- 
ing that it must have been taken up by the circula- 
tion ; and also cases of its manifest effect on the peri- 
osteum in a short time after having been applied to 
the cavity of a tooth the pulp of which is dead — thus 
proving that it must have been absorbed by imbibition. 
If arsenic is ever employed in- the treatment of 
sensitive dentine, it should be suffered to remain in 
the cavity but a short time, — from one to three hours, 
— and then the part with which it was in contact 
should be very thoroughly excavated. In deciding 
in what case it is proper to use it, there is need of 



284 PATHOLOGICAL CONDITIONS. 

careful discrimination as to the tooth's structure and 
density, for injurious results have sometimes followed 
its application, notwithstanding the utmost care ; if it 
has once passed into the dentine, antidotes will avail 
nothing. On the whole, therefore, it is better to re- 
frain from its use altogether in the treatment of sen- 
sitive dentine. 

Alkaline caustics have been to some extent used for 
the treatment of this affection. A preparation made 
after the following formula is said to relieve some 
cases very promptly : Take Canada balsam and slacked 
lime, and having made them into a paste, fill the cav- 
ity with it, and permit it to remain until the object is 
accomplished. 

The sensitiveness of dentine may be obtunded by 
friction on the affected part with a smooth burnisher. 
This method, however, is applicable only to those 
cases in which there is room to use the instrument. 
On the surfaces of the teeth, where there may be sen- 
sitiveness, it is very applicable and very efficient. 
Simple jjressure, without friction, it is suggested, will 
accomplish the same object, though pressure and fric- 
tion combined are doubtless more efficient. 

During the last three or four years, various appli- 
cations have been introduced, and used to greater or 
less extent, for the relief of sensitive dentine during 
the operation of filling. Moistening a cavity with 
creosote, carbolic acid, carvacrol,. or oil of cloves, at the 



TREATMENT OF SENSITIVE DENTINE. 285 

time of operating, and especially in excavating, will 
in many instances greatly mitigate the pain, and in 
some relieve it altogether. Many preparations have 
been devised and used for obtunding or destroying the 
sensitiveness of inflamed dentine ; some of them have 
been quite efficient. 

The following preparations have been used and are 
valuable in the topical treatment of sensitive dentiue, 
creosote, carbolic acid, oil of cloves, oil of cedar, oil 
of eucalyptus, and, indeed, most of the essential oils, 
glycerin and tannin, creosote and tannin. 

Various compositions are made with these, and sim- 
ilar ingredients, nearly all of which are valuable. 
Glycerin and carbolic acid solution may be used with 
very good effect when heated; it should be applied at 
first at such a temperature as to produce little or no 
pain, and the heat increased as the applications are 
renewed, until the desired effect is produced. 

Camphor and chloral solution is used in some cases 
with good results. 

It is well to bear in mind, however, that no one 
preparation meets the requirements of every case; 
some will accomplish the desired result in one case, 
and be wholly inefficient in another. 

The use of any of these things, even though they 
would in any case give temporary relief, do not meet 
the difficulty in a proper manner, except in those 
cases in which the affection is very superficial ; in 



286 PATHOLOGICAL CONDITIONS. 

every other case the aim should be complete restora- 
tion to a normal condition, and this for the most part, 
at least, must be accomplished by nature, aided,, so far 
as practicable, by proper systemic and local treatment. 
Many suppose that if they can by any temporary 
obtunding of sensibility introduce a filling, all will be 
well. This sometimes proves to be a serious mistake, 
for when a filling of metal is placed on sensitive den- 
tine, the thermal changes very often prevent a re- 
turn to a normal condition, and in some cases greatly 
increase the difficulty. In all instances, so far as pos- 
sible, an entire restoration to a state of health should 
be effected before filling, or the part shielded by a 
non-conductor. 



CHAPTER IX. 



EXPOSED PULPS. 



When the pulps of the teeth are exposed it is 
usually in consequence of decay, but sometimes of 
a gradual wearing down of the organs in mastication; 
in other cases by chemical abrasion. When the pulp 
of a tooth is found exposed, the course of treatment 
to be pursued will be indicated by the following con- 
siderations : 

1st. The constitution and the vital energy of the 
system. 

2d. The condition of the mouth and teeth. 

3d. The condition of the pulp. 

4th. The size of the orifice at which it is exposed. 

5th. Whether the exposure is of recent or of re- 
mote origin. 

6th. If in a tooth of more than one root. 

7th. The position of the tooth in the mouth, and 
that of the decayed cavity in the tooth. 

The propriety of attempting to preserve the vi- 
tality of the pulp after exposure has been questioned. 
Some take the position that after the development 
and formation of the tooth, the pulp is no longer of 
any use, and may, without damage, be dispensed 



288 EXPOSED PULPS. 

with; while others maintain that when the pulp is 
destroyed the tooth is no longer of any value. The 
truth is. perhaps, a medium between these extremes. 
The pulp of the tooth is valuable in the economy, or 
nature would dispense with it. Analogy teaches that 
it would not be retained longer than it could serve 
some beneficial purpose. But it is also true that a 
tooth may be retained and perform its proper func- 
tion for a long time after the destruction of its pulp, 
notwithstanding it is in a less perfect condition; 
though it is always desirable to preserve the life of 
the tooth when practicable, for the crown depends on 
the pulp for its vitality, and living dentine presents 
more resistance to decay than dead; besides, a dead 
tooth never exhibits the bright, life-like appearance 
of a living one. The parts about a dead tooth, too, 
are far more liable to disease than those about a liv- 
ing one. These are a few of the considerations for 
retaining the pulps of the teeth. 

It has been maintained that the structure of the 
tooth-pulp is of such peculiar character, and so sus- 
ceptible of diseased action that after it has become 
affected, though but slightly, it cannot be restored to 
a healthy condition. We see no ground, however, 
for such an assumption, except it be in the imperfect 
treatment which this organ so frequently receives; 
for the fact of its delicate structure does not neces- 
sarily imply an impossibility of restoring it from dis- 



TREATMENT OF EXPOSED PULPS. 289 

ease. The pulp of the tooth is endowed with such 
functions as ordinarily render living tissues suscep- 
tible of treatment for abnormal conditions, such as 
circulation, nutrition, absorption, and a distribution 
of nerves. The success attending the methods of 
treating exposed pulps practiced by the dental pro- 
fession during the last few years is a source of more 
encouragement than a thousand theories. 

Treatment of Exposed Palps. — In cases where the 
conditions are favorable, — the constitution good, the 
pulp but recently exposed at a small orifice, and in 
a healthy condition, — treatment may be instituted 
with almost absolute certainty of success. If there 
is no inflammation or irritation, therapeutic treat- 
ment is not indicated; but the decay should be re- 
moved and the cavity formed without wounding the 
pulp, if pos'sible: though a slight wound is of no 
serious consequence, for immediately after the haem- 
orrhage ceases the operation may proceed as though 
the pulp were intact. There have been suggested 
various methods for protecting the pulp in cases of 
this kind; formerly the capping of pulps was exten- 
sively practiced, by which a shield was thrown over 
the exposed point, so as to prevent the filling from 
coming in contact with it. Various materials have 
been suggested and used for caps, but gold and lead 
were formerly used for this purpose, especially when 
the object was to form an arch over the point of ex- 

19 



290 EXPOSED PULPS. 

posure. These caps are cut out of thin gold plate, or 
thick sheet-lead, of the proper shape and size, and 
stamped with a convex punch, thus receiving such a 
concavity as fits them for covering the exposed pulp 
without touching it. A little groove, of depth suffi- 
cient to hold the cap, and prevent it from being dis- 
placed by the introduction of the filling, may be made 
in the dentine all round the orifice of exposure. The 
cap is then to be adjusted to its position in the 
cavity, having been previously touched round its 
edge with adhesive wax; the filling is then intro- 
duced in the usual manner, carefully, so as not to 
displace the cap ; and, if this is of lead, great caution 
is to be observed in condensing the filling above it 
since it will be easily compressed. 

The therapeutic influences of lead on exposed 
pulps is supposed by some to be definite and decided; 
but, though lead is a less perfect conductor of heat, 
and, in this respect, is better than gold, and though 
in the capacity of a pulp-cap its indestructibility is 
probably quite sufficient, yet, if no change takes place 
in it, it is not very apparent how it. exercises any 
therapeutic action on the pulp. Experience, how- 
ever, proves that the success is quite as good in the 
use of lead caps as in those of gold, and the former 
are more easily applied. 

Another method of shielding an exposed pulp is, 
to form an arch over it by the filling. This operation 






TREATMENT OF EXPOSED PULPS. 291 

is performed by beginning the filling at that side of 
the cavity most easily approached, building on the 
gold from the points of its attachment almost to the 
point at which the pulp is exposed, and then attach- 
ing from one point to another without permitting the 
gold to come in contact with the pulp. Care should 
be taken that the gold present as smooth a surface to 
the pulp as possible. When the orifice of exposure 
has been well covered and protected, the remaining 
portion of the cavity is filled as usual. This method 
of forming a protection over a tooth-pulp possesses no 
advantage over the ordinary cap ; and being much 
more difficult, it is impracticable in any but skilful 
hands. 

This practice with exposed pulps, however, has 
within the last few years been almost wholly aban- 
doned, for the following reasons: because it so fre- 
quently nii led to accomplish the object, and because 
a better method of treatment has been discovered. 
It was found that, under that practice, many cases 
which at first promised well did not preserve the life 
of the pulp, though the fatal results were not always 
immediate — a year or two, and in some instances a 
much longer period, intervening between the opera- 
tion and the death of the tooth. In favorable cases, 
the pulp, even after exposure, will, if protected from 
the influence of foreign substances, throw out a bony 
deposit, and even close up an orifice of exposure, 



292 EXPOSED PULPS. 

thus forming for itself a natural shield. It is sug- 
gested that the capping operation is not the best pro- 
tection for facilitating this process. It is probable 
that in some cases the space between the cap and the 
pulp, though it were large, would be filled with lymph; 
and even if it were thus filled, a bony deposit might 
not be made ; and if it were not, it could not fail ul- 
timately to prove injurious to the pulp. But if the 
space should not be filled with lymph, the difficulty 
would be equally as great, since the pulp would pro- 
trude through the vacuum beneath the cap, and nec- 
essarily become diseased, since it would be irritated 
by its contact with, and its pressure against, the sharp 
edges of dentine at the orifice of the cavity ; and it 
may remain thus diseased for a long time, or die at 
once. Thus it is, no doubt, that the great majority 
of failures occur under this kind of treatment. In 
order to obviate this difficulty, it has been suggested 
that the space under the cap be filled with some ap- 
propriate substance, as a thick solution of gutta-percha 
and chloroform, or a small pledget of cotton saturated 
with collodion, 

The frequent failures which occur in capping pulps 
have incited the profession to seek some other method 
of treatment. A vacuum above the pulp being ob- 
jectionable, some suitable material is employed as a 
shield for this, being placed on the orifice of expos- 
ure, in contact with the pulp ; and the filling is then 



TREATMENT OF EXPOSED PULPS. 293 

introduced without pressure upon the point of expos- 
ure. There are several substances that have been 
thus employed, the chief of which are asbestos, oiled 
silk, collodion, gutta-percha, Hill's stopping, and os 
artificial. The material for this purpose should be a 
non-conductor of heat, should not be subject to de- 
composition when in contact with the pulp, should be 
non-irritant and should present a smooth surface and 
be easily adapted. In shielding the pulp in this 
manner, it is important that pressure be not made 
upon it ; and there is not much liability to this, where 
the orifice of exposure is small, but where it is large, 
much care is required in the introduction and con- 
solidation of the plug. The opinion has been enter- 
tained by some that the pulp of a tooth will not tol- 
erate any foreign substance in contact with it; but 
facts refute such an opinion. By this kind of protec- 
tion for a pulp, secondary dentine is more likely to 
be developed. 

A very efficient covering for an exposed pulp may 
be made by dropping on it a little collodion or solu- 
tion of gutta-percha, and after the evaporation of the 
ether or chloroform filling over it. This method has 
the advantage of completely filling and occupying the 
space, and exactly conforming to the part, which is 
an important requisite in this operation. When the 
exposure is at a large orifice, if the pulp is healthy, 
and the constitution of the patient good, the same 



294 EXPOSED PT7LPS. 

general course of treatment may be adopted, except 
that more care and skill will be necessary in the 
performance of an operation. Indeed, it is difficult 
to make a good operation in cases of this kind, using 
for the covering only a soft or flexible material. 

A method of operating that is probably more effi- 
cient than those already mentioned, is to prepare the 
cavity as described, place on the pulp two or three 
drops of collodion or solution of gutta-percha, letting 
it partially stiffen, and then over this fit a gold or 
lead cap as exactly as possible, so that it shall rest 
on the solid dentine, far enough from the orifice of 
exposure to preclude it from injurious influence on 
the pulp. On this, the filling is introduced as usual, 
care being had not to displace the cap, which in all 
cases should have a seat made for it, formed at the 
time of the preparation of the cavity. 

When the pulp of a tooth becomes, by exposure, 
inflamed or diseased, some more special treatment is 
indicated, and usually it is therapeutic. In every 
such case, the treatment will contemplate either the 
preservation of the pulp, when the circumstances 
will warrant ; or when they will not, then its destruc- 
tion and removal. The former of course is always to 
be preferred, where practicable. Some of our best 
operators very strongly denounce the wholesale de- 
struction of the pulps of the teeth, practiced by many; 
while some dentists never attempt to restore and pre- 



TREATMENT OF EXPOSED PULPS. 295 

serve them at all, however slightly diseased. This, 
as elsewhere intimated, is an erroneous practice ; for 
there is no obvious reason why the pulp of a tooth 
may not be restored from disease to health as readily 
as other parts, endowed as it is with circulation, nu- 
trition, absorption and the distribution of nerves. 
The particular kind of treatment required in any 
given case, however, will be controlled by various 
circumstances, such as the susceptibility of the case, 
the nature and extent of the disease, whether it is of 
chronic or acute type. When the irritation or inflam- 
mation is but slight, and is kept up solely by the con- 
tact of irritating substances, restoration of the pulp 
may be effected by a removal of these irritating 
causes, and protection of the pulp against their fur- 
ther influence : in such case, nature, unaided, effects 
the restoration. In a feeble constitution, the pulp, 
though but slightly affected, will require topical thera- 
peutic treatment ; and meanwhile general treatment 
may be employed to give increased tone to the sys- 
tem. In the local treatment, neutralizing agents 
should be applied first, and afterwards such as will 
counteract and reduce inflammation, especially if this 
is in an active state. But if the pulp is in a morbid 
condition, with retarded circulation and a tendency 
to enlargement, active and stimulating applications 
will be indicated, and in some cases escharotics, such 
as nitrate of silver, chloride of zinc, and chromic acid, 



296 EXPOSED PULPS. 

the latter especially where there is a tendency to pru- 
rient enlargement of the pulp. The therapeutic prin- 
ciples embraced in astringents, tonics, stimulants, and 
escharotics, are mainly to be relied upon in the topi- 
cal treatment of exposed pulp. 

The length of time requisite for this treatment will 
vary with different cases. In the case of a recent 
acute inflammation, the process of restoration may be 
completed in two or three days ; while in other cases, 
where the difficulty is of long standing and of a more 
complex character, it will require from a week to two 
months. The systemic condition of the patient also 
exercises a great modifying influence upon the treat- 
ment. Leeching and counter-irritation of the gums 
are sometimes resorted to in this treatment ; but it 
is rare that any definite beneficial result ensues. De- 
pletion of the pulp itself may often be practiced 
with decided success; and it may be accomplished 
either by puncturing the pulp with a fine-pointed in- 
strument, or by excising a small portion of it at the 
orifice of exposure, in either case avoiding laceration. 
By this means the distended vessels are relieved ; 
and in many cases, where the difficulty is but slight, 
immediately after such relief by puncturing, so soon 
as the haemorrhage has ceased, the tooth may be 
filled. But if the depletion is by excision, time must 
be allowed for the recovery of the incised surface- 
ordinarily from three to ten days. 



TREATMENT OF EXPOSED PULPS. 297 

A method of treatment of exposed pulps — first 
introduced to the notice of the profession hy Dr. 
Allport, and one which in his hands has proved quite 
successful — consists in the excision of a portion of 
the pulp at the orifice of exposure, drawing the 
edges of the incised part together, and inducing their 
union, and in this manner closing the wound, when 
less space is occupied by the pulp than before the 
operation. After securing this result, the operation 
of filling the tooth may be performed ; the same care 
being observed, however, as already suggested in 
cases of exposed pulp. 

The employment of pepsin has been quite effective 
in the hands of some practitioners. The method of 
application is as follows : with the pure pepsin in 
powder, and diluted hydrochloric acid, or liquid pep- 
sin, form a paste of creamy consistence, that can be 
readily applied to an exposed pulp. 

The cases in which this preparation seems appro- 
priate and efficient are those in which there is debris 
and offensive matter in contact with and irritating 
the pulp that cannot be readily removed, either with 
an instrument or by washing. There is often a film 
of partially devitalized pulp-substance upon and cov- 
ering the exposed part, that operates as an active 
irritant to the tissue beneath it ; this and all similar 
substances are dissolved and removed by the action 
of the pepsin paste ; and not only is this accom- 



298 EXPOSED PULPS. 

plished, but the pulp is stimulated to a healthy ac- 
tion. 

For the application the cavity through which the 
exposure is effected should be cleaned thoroughly and 
dried ; then place a drop of the paste on the point of 
exposure, on this put two or three plies of bibulous 
paper, then fill the cavity with wax, softened by 
heat, so that its introduction will not cause pressure 
upon the pulp. This should remain for from six 
to twenty-four hours, when it should be removed ; 
the pulp will usually now present, at the orifice of 
exposure, the bright pinkish hue of the healthy 
tissue ; very seldom will a second application be re- 
quired. 

This condition being attained, the pulp is ready 
for its covering for permanent protection. 

For the proper covering and filling over an ex- 
posed pulp, certain indications must be fulfilled. 

First. A material must be used that will be ac- 
ceptable to the tissue, that will in no degree irri- 
tate it. 

Second. It should be a substance that will not de- 
compose or undergo change when in contact with the 
pulp. 

Third. It must be a material of such consistence 
as to be made easily to occupy all the space at the ori- 
fice of exposure, and yet make no pressure upon the 
pulp. 



TREATMENT OF EXPOSED PULPS. 299 

Fourth. It should be a non-conductor of heat equal 
at least to the dentine. 

Fifth. It should possess sufficient resistance to 
admit the proper introduction of the best material 
for filling. 

Thus it is apparent that the aim is, and should be, 
to place the exposed pulp again in as nearly its nor- 
mal state of closure as possible. This is the criterion 
that should guide in the performance of this most 
delicate operation. 

A very good method of accomplishing this was 
suggested by Dr. J. S. King about the year 1871. 
Others have claimed that they had used the same 
principle before ; but such claim is not established ; 
certainly he was the first to bring it to the notice of 
the profession. 

It consists in placing in the orifice of exposure and 
on the pulp, after it has been freed from all irritants 
and debris, and restored to a state of health as nearly 
as possible, a paste of oxide of zinc and a solution of 
creosote of a thick creamy consistence ; with this 
the orifice should be completely covered ; remove 
any excess of creosote with bibulous paper ; then 
cover this, and fill the cavity of decay with os artifi- 
cial or Guillois' cement, or better now, With oxy-phos- 
phate of zinc, which is non-irritant. So far as the 
pulp is concerned, this is to be the permanent cover- 
ing; as to the cavity of decay, this may constitute 



300 EXPOSED PULPS. 

the permanent filling, or sufficient of the os artificial 
may be cut away from the cavity to enable it to be 
well filled with gold, or any other material. This in 
the hands of many has proved a very successful 
method of inclosing exposed pulps. 

The formation of secondary dentine, by which the 
orifice of exposure is closed, has already been re- 
ferred to; and it has been suggested that treatment 
to facilitate this process may be instituted. With a 
view to this, temporary fillings are sometimes intro- 
duced. If a shield of secondary dentine is desirable 
before permanent filling, the best method of securing 
it is, after seeing that the general recuperative power 
is in the best condition, to place in the cavity a tem- 
porary filling, of such material and in such manner 
as will be most acceptable to the pulp, and then leave 
nature to accomplish the work. In many cases, es- 
pecially in young persons, this process would be fa- 
cilitated by an administration of bone phosphate. 
The pulps of the teeth of the young are more diffi- 
cult to treat successfully than those of the more ad- 
vanced in life. 

A method of treating exposed pulps with a view 
of securing a closure of the orifice of exposure by na- 
ture, was first suggested and practiced in 1873, by 
Dr. J. E. Cravens, and consisted of the following 
treatment: 

The exposed pulp should be rendered as nearly 



TREATMENT OF EXPOSED PULPS. 301 

absolutely free from extraneous matter as possible, 
but softened or partially decalcified dentine may re- 
main undisturbed in the cavity. The cavity should 
be secured against moisture, and kept so during the 
operation; being thoroughly clean and dry, the pulp 
exposure should be covered with a paste prepared as 
follows: Upon a warm slab of ground glass put a 
drop of Merck's lactic acid; add twice that volume 
of magma, or freshly precipitated phosphate of lime; 
then rub till a complete solution is effected. This 
is lacto-phosphate of lime. To this solution add dry 
phosphate of lime until the paste is of proper consist- 
ence for application. Place this paste directly on the 
exposed pulp so as to occupy all the space and yet 
make no pressure upon it; the cavity may be filled 
from one-fourth to one-third full of this material; 
then remove the moisture from the surface of the 
paste with spunk, or some absorbent, then cover it 
with two or three plies of bibulous paper, cut to fit 
the cavity and moisten with sweet oil ; press this 
carefully upon the paste, especially all round the 
border; then cover this and fill the cavity with os 
artificial, or its equivalent. Hill's stopping or gutta- 
percha cannot with safety be used instead of the os 
artificial, as more or less pressure would be occasioned 
by their introduction. Dr. Cravens suggests that 
the pulp should not be treated previously with any- 
thing that would coagulate albumen, and, indeed, 



302 EXPOSED PULPS. 

should have no preparatory treatment except that 
already referred to. 

This dressing and filling should remain undis- 
turbed for from two to six weeks, and one application 
is usually quite sufficient to induce bony deposit to 
fill the orifice of exposure and cover the pulp. 

Pain will seldom be experienced after the applica- 
tion of the phosphate of lime as above described, 
but if it should the use of sedative treatment, either 
locally or through the system, will meet the diffi- 
culty. In no case should the dressing and filling be re- 
moved or disturbed till the allotted time has elapsed. 
Dr. Cravens entertains the opinion that the phosphate 
of lime, thus applied, is appropriated in the forma- 
tion of the new deposit, and that thus the living 
tissue beneath has co-operation in this process, at 
least so far as supply is concerned. 

Destruction of the Pulp. — There are cases in which 
an attempt to restore the pulp, even when recently 
and but slightly diseased, would prove unavailing; 
so feeble is the vitality that it is destroyed at almost 
the first touch. Two cases in apparently the same 
condition pathologically, but in different constitu- 
tions, will, under the same treatment, exhibit very 
different results. A pulp in a system with low vital 
power, that is highly diseased, is but seldom, if ever, 
under any circumstances, susceptible of restoration ; 
and in such case of course, devitalization and re- 



REMOVAL OF PULPS. 303 

moval are indicated. This was formerly supposed to 
be an impracticable operation, for two reasons: first, 
because it was very difficult and painful; and second, 
because of the consequences likely to ensue. Then, 
the operation was attempted only on teeth having 
one root, and those of cylindrical form; but now, it 
is performed successfully on all classes of teeth. When 
destruction of the pulp is decided upon, such means 
should be employed as will effect the object promptly 
and thoroughly. Everything should be entirely re- 
moved from the pulp-chamber and the canal of the 
root, for any remaining portion is liable to induce in- 
flammation and suppuration; and alveolar abscess 
also frequently ensues. 

There are two methods of destroying the pulp; 
the one by an operation; the other by the applica- 
tion of some devitalizing agent. The choice of these 
methods will be governed by circumstances, such as 
the temperament of the patient, the condition of the 
tooth and parts about it, and the class of the tooth 
to be operated upon. For patients of a nervous, ir- 
ritable temperament, to whom a removal of the pulp 
by an operation would occasion great pain and a se- 
vere shock, it would be better to apply some agent to 
destroy the vitality of the pulp, and then remove it; 
but, on the contrary, where there is vigor, and a ca- 
pacity of endurance, it is preferable to remove the 
pulp at once by an operation. To accomplish this, 



304 EXPOSED PULPS. 

there are two or three methods of manipulation. In 
the first place, however, by whatever method it is 
removed, it should be fully exposed; the orifice of ex- 
posure should be as large as the pulp-chamber, and 
the entrance as nearly as possible on a line with the 
tooth's axis; hence it will be necessary, in many 
cases, to make an opening into the pulp-chamber at 
a point different from that of the opening produced 
by the decay. For instance, in the incisor teeth, 
when the decayed cavity is small, on the side near 
the margin of the gum, penetrating to the pulp-cham- 
ber, and exposing the pulp, the entrance through 
this opening into the canal will be almost at right 
angles with it; and in such case it would be impos- 
sible, through this opening, to manipulate freely in 
the root, and it would be necessary to make an open- 
ing with a drill through the palatal portion of the 
tooth directly into the canal and on a line with it, 
which opening should be large enough readily to al- 
low of a removal of the pulp through it, and of an 
unimpeded performance of all the subsequent opera- 
tions in the canal of the root. 

After the pulp has been exposed by the proper 
opening, the instrument should be selected for its re- 
moval. There are different forms of instruments for 
this purpose. Some operators employ the untem- 
pered, four-sided, barbed broach, thrusting it into 
the canal as far as possible, then turning it two or 



REMOVAL OF PULPS. 305 

three times around, and thus wrapping the pulp round 
the instrument, when both are drawn away together. 
This method always occasions considerable pain. 
Others employ simply the three or four-sided broach, 
thrusting it through the pulp all the way up the 
canal, and thus lacerating it and breaking up its 
structure, so that it may afterward be removed with- 
out much pain. Another method and one which 
seems preferable to all the others, is as follows : 
Take a very fine untempered steel wire, round and 
smooth, not larger than 34 to 36 of Stub's gauge- 
plate ; flatten the extreme point, and turn it to an 
angle of from thirty to forty degrees ; place the edge 
of this against one wall of the canal at the point of 
exposure of the pulp ; press it steadily up the canal, 
with its edge bearing against the wall as far as it will 
go, and then twirl it suddenly round. Thus an ex- 
cision is effected near the point of the root, when the 
pulp with the instrument may be drawn away to- 
gether ; or, if not thus removed, it may be caught with 
some fine point, and removed with little or no pain, 
This manner of introducing the instrument,, too, 
causes less pain than either of the others, for there 
are no sharp edges or points presented in passing the 
instrument up the canal, to cut or lacerate the pulp. 
In the removal of the pulp from the teeth of young 
persons, care should be taken lest the instrument 
pass entirely through the foramen, at the apex of 

20 



306 EXPOSED PULPS. 

the root; but with adults there is little or no danger 
of such an accident. 

The directions here given would be quite sufficient, 
if closely followed, for the removal of the pulps of 
the six anterior superior teeth. For the removal of 
the pulps from the bicuspids, the entrance can ordi- 
narily be effected through the decayed cavity. Usu- 
ally there is some lateral compression of the roots of 
these teeth ; and the canal through the root corre- 
sponds in its formation, so that it presents a mere 
fissure, expanded a little on each side of the centre. 
It is often difficult, and requires very delicate manip- 
ulation, to remove all the pulp from these fissures. 
A very fine instrument may be pressed down each 
side, and yet a portion of the pulp remain in the 
centre. This difficulty is most fully presented in 
those cases in which there has been an apparent, 
though abortive, effort of nature to produce two 
roots. 

The removal of the pulps of the molar teeth is a 
more extensive and complicated operation. The pulp 
to be operated upon should be fully exposed, the ori- 
fice of exposure being made as nearly as possible of 
the size of the pulp-chamber ; and the instrument to 
be used should be such as last described, except that 
it should be much larger, and is to be introduced, in 
the same manner, to the bottom of the pulp-chamber, 
and rotated suddenly, so as to cut off the ramifica- 



REMOVAL OF PULPS. 307 

tions of the pulp into the roots, thus at one sweep 
dislodging the entire body of it without laceration. 
The practice of plunging a large barbed or cutting 
instrument into the pulp of a molar tooth is painful 
in the extreme. 

The pain of removing the living tooth-pulp may be 
much mitigated in all cases, and in many prevented 
altogether, by the use of local anaesthesia. This may 
be effected by the application of chloroform, or some 
one of the various anaesthetics that are available, di- 
rectly to the pulp. The application of cold is quite 
efficient ; this may be effected by the use of ether 
spray or ice. So extended have become the facilities 
for inducing local anaesthesia, that the spray or ice 
need hardly be employed. 

The branches of the pulp in the roots should be 
removed in the manner already directed for the re- 
moval of the pulps from teeth of single roots. The 
palatal root is very easily operated upon ; but as to 
the buccal roots, there is frequently encountered the 
same difficulty referred to in speaking of the bicus- 
pids. When a pulp is removed in this manner, the 
wound commonly heals by first intention, and there 
is formed a permanent cicatrix. 

Actual Cautery. — For destroying tooth-pulp, the 
actual cautery was formerly employed to a consider- 
able extent, and was at one time a favorite method 
with French dentists. This consists in heating a 



308 EXPOSED PULPS. 

wire of proper size to a white heat, and thrusting it 
into the canal of the root to the apex, the object be- 
ing to destroy the pulp the instant the wire comes 
in contact with it. The operation requires much 
skill, and is attended with many difficulties. It is 
fraught with terror to the patient ; if the temperature 
of the wire is not at white heat at the time of its in- 
sertion, the pain of the operation is most intense ; 
it is liable to leave the parts in such* a condition as 
often to induce inflammation and suppuration, which 
may involve the investing membrane and the sur- 
rounding parts. Besides, by this method, the object 
is, at best, no more successfully attained than by 
others. 

The galvanic cautery has been employed to some 
extent in general surgery, and it is very probably the 
best form in which the actual cautery can be applied 
for destroying pulps of teeth. 

Potential Cautery. — This term is applied to those 
therapeutic agents which destroy vital tissue by es- 
tablishing a condition incompatible with vitality. 
Many preparations have been employed as topical 
applications to devitalize the pulps of teeth, but only 
two or three to any considerable extent. A consid- 
eration of the nature and something of the specific 
action of these agents may not here be out of place. 
And first, of 

ArseniousAcid. — This has been more used, topically, 



REMOVAL OF PULPS. 309 

for the destruction of tooth-pulp than all other appli- 
cations. The first account we have of its use for this 
purpose dates back to 1836, when it was applied by 
Dr. Spooner, though others claim to have employed 
it about the same time. The specific action of arseni- 
ous acid on vital tissue is not well understood. It 
is supposed by some that it forms a compound with 
some element of the tissue, and in this way destroys 
the vitality. 

Any such combination, however, has hitherto es- 
caped detection ; and it is certain that if a compound 
is formed, it is not fixed or permanent in its charac- 
ter, since the arsenic will be carried to different parts 
of the system, and its specific influence manifested 
wherever it goes, which could not be the case if it 
formed a fixed compound. The more probable the- 
ory is that it destroys vitality by its influence on 
nerve tissue, producing such a change in its structure 
as to arrest its function at once. In reference to the 
action of this agent upon living tissue, much investi- 
gation remains to be made. Animal tissue takes it 
up by imbibition ; and it is also absorbed by the cir- 
culation, and conveyed by it, as already suggested, 
throughout the system. Frequently, however, it is 
applied to living tissue, under conditions that pre- 
vent such absorption. It is often employed in the 
treatment of carcinoma. In the application of arse- 
nious acid to the pulps of teeth, for their destruc- 



310 EXPOSED PULPS. 

tion, several circumstances are to be considered, such 
as the age of the patient, the constitutional tendency, 
the vascularity of the dentine. Where the vascular- 
ity is great, the utmost caution is required. The in- 
discriminate use of this agent in the teeth of the 
young is attended with great risk. Some constitu- 
tions are peculiarly susceptible to its influence, expe- 
riencing its effects even in remote parts of the system, 
after its application only to the pulp of a tooth. It 
is soluble in creosote and most of the essential oils, 
and to some extent in alcohol and water. In many 
cases when it is applied to the pulp of a tooth, more 
or less disturbance of the periosteum is exhibited a 
short time after — -in some instances in a few hours, 
and in others after several days, thus giving evidence 
that it has by some means come in contact with the 
periosteum. Its influence on this will often be mani- 
fested under percussion, in advance of any other 
symptom. 

Application. — There are two or three methods of 
applying arsenious acid for the destruction of the 
pulps of teeth. The ordinary arsenic of commerce is 
used. It was formerly employed very extensively in 
connection with sulphate of morphia, mixed in equal 
parts, and applied to the pulp with a small pledget 
of cotton, moistened with creosote or some essential 
oil, the former being most frequently used. Alcohol, 
ether, or water may be employed instead of creosote, 



REMOVAL OF PULPS. 311 

and in some respects and in some cases would be 
preferable. The pledget of cotton, thus prepared, is 
introduced into the decayed cavity, with the prepa- 
ration in contact with the exposed pulp. Another 
pledget of cotton, saturated with a thick solution of 
gum-sandarac and alcohol, or gutta-percha and chloro- 
form, is placed over this in the cavity, to prevent 
the escape of the preparation, or the entrance of mois- 
ture or foreign substances. Any preparation may be 
used that will accomplish these objects. In the ap- 
plication of the pledget, care must be exercised lest 
too much pressure be made on the pulp, and pain be 
thus produced. In order to prevent this pressure, 
another method has been adopted, which consists in 
forming a cap of lead, placing it in the arsenic, in the 
dry state or with some suitable solvent, and then fit- 
ting it over the exposed pulp, and retaining it there 
with a pledget of cotton, as above, or with Hill's stop- 
ping, gutta-percha, or adhesive wax. Thus the prep- 
aration comes gently in contact with the pulp, and 
prevents any pressure on it. The morphine is used 
for the purpose of diminishing the pain which fre- 
quently results from the application of arsenic only ; 
but its influence for such a purpose is predicated more 
on theory than on practice ; for facts prove that, ap- 
plied to living tissue, it produces pain rather than al- 
lays it. Therefore the more observing and better 
class of practitioners have discarded it. 



312 EXPOSED PULPS. 

Other substances have been mixed with arsenic, 
for the purpose of mitigating or altogether relieving 
the deleterious consequences so liable to follow its 
administration ; as, for instance, pulverized charcoal, 
which, mixed with it in equal parts by weight, 
makes a favorite preparation with some practitioners, 
by whom it is claimed that the charcoal counteracts 
the specific effect of the arsenic on parts other than 
those for which it is directly designed. But this 
theory, in the light of any elucidation yet given, is 
very vague. The claim cannot be that charcoal is 
an antidote to arsenic, since facts refute it ; for if it 
were, the arsenic of the preparation, when applied to 
the pulp of a tooth, would fail of its effect, because, 
the charcoal being also in contact with the pulp, 
would there, if ever, counteract the poison. But this 
it does not do, for the pulp is destroyed about as 
readily by this preparation as by arsenic alone. And 
if when the arsenic and charcoal are thus together no 
counteracting influence of the latter is manifest, 
much less will there be any when the arsenic, es- 
caped from the charcoal, runs riot through the tis- 
sues, whither the latter cannot follow. The only 
probable advantage, then, of this preparation is, that 
the arsenic is not taken up from it by the tissues 
so rapidly as when it is applied alone, or with any- 
thing that is soluble with it ; for when thus applied, 
the whole is very soon dissolved, and taken up by 



REMOVAL OF PULPS. 313 

the pulp and dentine. But when mixed with char- 
coal or the like, little more of the arsenic is absorbed 
than that which comes in contact with the pulp. 
Hence the conclusion that the influence of the char- 
coal is mechanical, and not therapeutic. 

This preparation is better applied perfectly dry, 
beneath a lead cap, which should completely close 
the cavity. Any other material that would mix as 
readily with the arsenic, without being soluble, and 
that would not induce irritation when in contact with 
the pulp, would be quite as good for this purpose as 
charcoal. Irritating gases generated in a tightly- 
closed cavity are absorbed by charcoal. 

Cobalt, in which the active principle is arsenic, 
has been extensively used for destroying pulps ; but 
it is in no respect superior, and in some respects it is 
probably inferior, to the preparation of charcoal and 
arsenic; it is applied in the same manner. 

The length of time the preparation should remain 
in the tooth will be determined by the condition of 
the pulp when it is applied, the age of the patient, 
the vascularity of the dentine, the susceptibility ol 
the patient to the influence of arsenic, and- like cir- 
cumstances. It will usually be from three to twenty- 
four hours. In some cases a very small particle will 
thoroughly accomplish the work, while in others a 
much larger quantity may remain in contact with the 
pulp even for a much longer time, without producing 



314 EXPOSED PULPS. 

more than a superficial result. And cases occasion- 
ally occur in which it seems almost impossible to 
destroy the vitality of a pulp with arsenic. A case is 
on record in which the pulp was first fairly exposed 
in a superior bicuspid tooth, the health and constitu- 
tion being good, and the temperament sangui no-lym- 
phatic ; and arsenic with morphine was applied to 
it, directly, five times within ten days, without pro- 
ducing any apparent effect; then an application of 
creosote and tannin was made three or four times 
during as many days ; afterward the tooth was tem- 
porarily filled with gutta-percha ; and finally, in ten 
or twelve days, this filling being removed, the pulp 
appeared in a perfect state of preservation and health, 
with all the indications of undiminished vitality. 
Over the exposed point there was placed a non-con- 
ductor, and upon it a filling of gold, and one year 
after, the tooth presented the appearance of perfect 
life and health, having given the patient no annoy- 
ance during the whole period. 

Hence, it is quite obvious that there is a great di- 
versity of susceptibility to the influence of arsenic, 
and that the study of these idiosyncrasies is both in- 
teresting and valuable. The occurrence of injurious 
consequences from the use of arsenic has induced 
many operators to abandon it altogether. But these 
injurious results may occur either through mal-ad- 
ministration or from a peculiar susceptibility to the 



TREATING PULP-CAVITIES. 315 

influence of the drug, and a superior skill and a more 
accurate diagnosis would render less frequent the 
characteristic injurious results. After the desired 
result with arsenic has been obtained, it has been 
thought that antidotes to arrest its further operation 
might be made available. The hydrated sesquioxide 
of iron is one of the best antidotes to arsenic, and 
has been used in the teeth to counteract its injurious 
effects ; but it is of no avail here, the arsenic has 
the start of it, and, indeed, would outstrip it with an 
equal start. 

From the foregoing, in regard to arsenic as an ap- 
plication for destroying the pulps of teeth, the fol- 
lowing conclusions are justly deducible : it is, in 
general, very efficient; it is a heroic agent; it should, 
in all cases, be used with great caution ; in some cases 
it is entirely inadmissible; a free administration of 
it is liable to be followed by bad consequences; and 
skill and care, rather than counteracting agents, are 
to be relied upon in its application. 

Filling Pulp Cavities and Canals. — After the pulp 
of a tooth has been destroyed, whether by an opera- 
tion or by an escharotic, the part at the point of its 
detachment should, in most cases, before the filling is 
introduced, be rendered healthy; if possible, a per- 
manent cicatrice should be formed. In cases, how- 
ever, of good constitution and strong recuperative 
power, where a pulp has been removed by an opera- 



316 PULP-CAVITIES. 

tion, the root may be filled as soon as the haemorrhage 
has ceased; but such cases rarely occur. Generally, 
the part will require treatment, and the character 
and duration of this will be determined by circum- 
stances — as, the vital energy of the system, and the 
method employed for the pulp's destruction. When 
this has been effected by an operation, the wound 
produced by an excision is restored to soundness 
much more readily than when by an application of 
arsenious acid, and less topical treatment will ordi- 
narily be required, indeed, in many such cases, there 
will be nothing else required than to keep the canal 
well cleansed, so as to obviate any irritation that 
otherwise might be induced by decomposition. When 
the pulp has been destroyed by arsenious acid, more 
energetic treatment is usually demanded, for then 
there is always a greater or less disposition to slough 
or discharge through the tooth, which must, of course, 
be entirely abated before the operation of filling is at 
all admissible. In the treatment of this condition 
the canal should be kept perfectly clean by frequent 
syringing; floss silk, moistened with creosote and 
tannin, should be introduced to the extreme part of 
the cavity or canal, and should be changed every 
twenty-four hours, the cavity being thoroughly 
washed each time. It will be necessary, in many 
cases, to continue this treatment for several days. In 
order to determine whether the condition is such as 



TREATING PULP-CAVITIES. § 317 

to admit of the filling, the floss silk should be re- 
moved after a sufficient time is supposed to have 
elapsed, the cavity thoroughly cleansed and dried, 
and a portion of dry floss silk or cotton introduced 
loosely into the canal. Then close the decayed cavity 
with adhesive wax, gutta-percha, or some other sub- 
stance that will effectually exclude the moisture; let 
it remain thus from twelve to twenty-four hours; 
then open the cavity and withdraw the silk or cot- 
ton, and if this is found free from moisture or odor 
the tooth is ready to be filled. 

The treatment just described will be sufficient for 
all cases in which the pulp has been destroyed by the 
operator. But teeth whose pulps are already dead 
would seem to be less difficult of treatment and fill- 
ing, yet such is not the case; indeed, the therapeutic 
treatment of these is usually more protracted, and 
their diseased condition less easily controlled; and 
this because of the fact that the decaying pulp re- 
maining in the canal becomes very offensive and 
irritating to the living parts adjacent, in which it 
induces a chronic diseased condition, frequently 
involving the dentine along the walls of the canal in 
decomposition. 

A classification of these teeth, based on their con- 
ditions, might be somewhat auxiliary to a further 
examination of this subject, and the following will 
probably embrace them all:. 



318 PULP-CAVITIES. 

1st. Those whose pulps are dead, but their attach- 
ments and adjacent parts alive and healthy. 

2d. Those predisposed to disease. 

3d. Those already diseased, either discharging ac- 
rid matter through the root, or exhibiting inflamma- 
tion of the periosteum. 

4th. Those having alveolar abscess. 

Sound or slightly decayed teeth are sometimes 
found with dead pulps. This condition may be pro- 
duced in various ways : by blows, or by any force 
that will partially loosen the tooth; by undue pres- 
sure in filling ; by excessive sensitiveness of the den- 
tine, even where the decay is not extensive ; and, 
sometimes, by a filling of the tooth when it is in an 
unfit state for the operation. Ordinarily, in cases in 
which the pulp is dead before its exposure, and there 
is no abscess from the root or periosteum, the pulp- 
chamber may be opened and the remains of the pulp 
removed. The canal should then be cleansed out, 
and floss silk, moistened with creosote, introduced 
and permitted to remain from one to six hours, when 
it should be withdrawn, the pulp cavity and the canal 
again thoroughly cleansed, when, if there is no dis- 
charge of pus through the root, it may be filled. The 
fact that the dead pulp is inclosed in its chamber 
without producing irritation is evidence that there is 
no secretion of pus. Occasionally, where the pulp 
has died from exposure, the living part immediately 



TREATING PULP-CAVITIES. 319 

adjacent will present a healthy condition, and there 
will be no discharge ; such cases should be treated in 
the manner just described. In operating on teeth 
already dead, more delicate manipulation is requisite 
to prevent irritation than on those in which the pulp 
is destroyed by the operator. In very many cases 
of dead teeth, where there is not a state of actual 
disease, there is a strong predisposition to it ; and in 
these cases the preparation of a cavity, or the intro- 
ducing and condensing of a filling, may produce in- 
flammation of the periosteum. When such a condi- 
tion is recognized, several sittings may be required 
to complete the operation. It is not always easy to 
recognize such a predisposition ; yet whenever it is 
suspected, it is well to press the investigation, which 
may be guided by the following rules. Ascertain 
whether the tooth experiences a different sensation 
or any pain under percussion in any direction ; 
whether periostisis has ever existed in that or in a 
contiguous tooth ; whether the parts adjacent to the 
tooth are in a healthy state ; whether there is a gen- 
eral inflammatory diathesis or an enfeebled condition. 
These are the principal points in an examination of 
this kind. 

Where this predisposition exists, it may be coun- 
teracted by general or local treatment, according as 
it depends on general or local causes ; but in every 
case, this treatment should be very carefully con- 



320 PULP-CAVITIES. 

ducted, and it will in some instances have to be pro- 
tracted. In those cases where there is a discharge 
through the root of the tooth, such treatment should 
be adopted as will most speedily and effectually sup- 
press it ; and if it proceeds from a remaining portion 
of the pulp-tissue near the point of the root, this 
should be removed, and such application made as 
will prevent a recurrence of the discharge, and assist 
the part to recover its health. The discharging sur- 
face may be broken up by cutting it away with an 
instrument, or be destroyed with an escharotic — 
either nitrate oft silver, creosote, or chloride of zinc, 
in the use of which, several applications will in many 
cases be necessary. From their action, the secreting 
surface is destroyed, healthy granulations spring up, 
and a healthy condition is established. 

The discharge should be wholly suppressed before 
the tooth is filled, otherwise alveolar abscess would 
probably occur. In cases where there is periostitis, 
it must be subdued before the tooth will tolerate the 
operation of filling. To attain this end, the treat- 
ment required will be indicated by the nature of the 
causes which operate to induce the disease. 

The periostitis of teeth whose pulps are dead com- 
monly has its origin at the point of the root, from 
irritation induced in the beginning by the dead and 
decomposing pulp and other matter at that point. In 
many instances the inflammation is not confined to 



TREATING PULP-CAVITIES. 321 

the root of the tooth on which it began, but it will 
extend to the alveolus, the gums, and the periosteum 
of the neighboring teeth. Whenever the existence 
of this disease is suspected, and yet not very appar- 
ent, as is often the case, the examination should be 
very thorough. In some instances, percussion of 
the tooth at one particular point, and at a certain 
angle, will produce pain ; whereas, striking on any- 
other part of the tooth, or at any other angle, will 
cause none at all. By proper care and discrimina- 
tion the exact point of disease, even if confined to a 
small space, may be ascertained. For instance, if 
striking on the labial surface of a central incisor, near 
the point, produces pain in the socket, while on any 
other point it does not, the place of the inflammation 
is the anterior portion of the root, at or near its point. 
By such means the skilful and discerning will be en- 
abled to form a tolerably accurate opinion as to the 
extent and location of periostitis in all cases ; and 
this is an important consideration, for if inflamma- 
tion is found confined to a small portion of a root, 
the treatment, if local, should be as near that point 
as possible. 

Inflammation of the periosteum may sometimes be 
induced by the presence of foreign substances forced 
down between the free margin of the gum and the 
neck of the tooth, which have remained there till they 
have become vitiated, so as injuriously to affect the 

21 



322 PULP-CAVITJES. 

gums and periosteum. A deposit of salivary calculus 
sometimes produces inflammation of the gums and 
periosteum. Teeth otherwise healthy are in some 
instances thus affected, though those which have lost 
their internal vitality are much more liable to such 
disease. 

Preparing the Teeth and Roots for Filling.— After 
the tooth has been brought to a healthy condition, 
the decayed cavity is first to be excavated and made of 
proper form, the pulp-chamber to be shaped, and then 
the canals and the roots to be prepared for filling. 
For the preparation of decayed cavities here, the di- 
rections hitherto given on that subject will be quite 
sufficient. In the formation of the pulp-chamber the 
abrupt projecting portions of dentine should be cut 
down, and if there is any decomposition of this it 
should be removed. The pulp-chamber may be, when it 
is excavated, of a general retaining form, or there may 
be retaining-points made within it at proper situations. 
In the preparation of the canal in the roots, some op- 
erators do nothing more than cleanse them thoroughly. 
Another method is to pass fine bur-drills into them as 
far as practicable, thus making the opening of the 
same size all the way, or to scrape out the canal with 
a fine No. 10 excavator. Very fine, delicate instru- 
ments are required for cleansing out and forming the 
canals, and they should be quite elastic and of low 
temper. A set of instruments for forming the canals 



FILLING PULP-CANALS, 



323 



in the roots of the teeth have been devised and made 
by Dr. Cory don Palmer. These are of such forms 
and sizes as to be suitable for every case. They are 
represented in Fig. 94. Before the introduction of 
these instruments the method of forming these canals 
was by the use of a three or four sided broach, taper- 
ing to a sharp point, and in inclination corresponding 

Fig. 94. 



I 





as far as possible to that of the canal. This instrument 
is employed to enlarge the canal and give it a regular 
shape; a variety should be at hand so that one of the 
proper size and taper can be selected. In cleansing 
and forming the canal, care is necessary to prevent the 
instrument from passing entirely through the point of 
the root. Such an accident is not very liable to occur 
with the tapered broach, but with the miniature ex- 
cavator, or barbed wire, it is, especially in the teeth of 



324 PULP-CAVITIES. 

the young, where the foramina through the roots are 
large, and it is especially liable to happen to the in- 
cisors, the cuspids, and the palatine roots of the su- 
perior molars. But after the complete development of 
the teeth there is no excuse for an accident of this 
kind, for then there is an abrupt contraction of the 
canal near the point of the root, which may always 
be detected by a careful introduction of the instru- 
ment. 

The decayed and pulp-cavities, and the canal, all 
being thus prepared, are now ready to receive the 
filling. For filling the root there are several methods, 
one of which is to prepare small strips of gold, of two 
or four thicknesses of foil, take these on the point of 
an instrument and pack them into the root, in suc- 
cessive folds, till the canal is full. Another method 
is to take small portions of gold and pack them in, 
one on another, till the canal is full. Another is to 
take strips of from two to four thicknesses, and from 
one to two lines wide, and roll them on a fine broach 
in such a manner as to make a cone-shaped block a 
little longer than the depth of the canal to be filled, 
and of the same taper; quite a number of these blocks 
will be required for any given case, of various sizes, 
lengths, and densities. The longest, largest, and least 
dense should be first used, the last requiring to be of 
less size and greater density. These cones may be 
made as dense as desirable by rolling them firmly be- 



FILLING PULP-CANALS. 325 

tween the thumb and fingers after having taken them 
off the broach. They are then introduced with the 
plugging-pliers, and passed up as near to the jDoint of 
the root as is consistent with safety. In some in- 
stances there is danger of thrusting them through the 
point, and, in order to prevent this, the end of the first 
block introduced may be made so large that it will not 
pass through, even when forced up ; or, what is prob- 
ably better, a very small round pellet of gold may be 
forced into the canal, as near to the point of the root 
as admissible, and this serves as a foundation for the 
subsequent portions of gold, and prevents them from 
passing too far. The cone-shaped blocks may be intro- 
duced and consolidated with an. instrument of the 
same general form as the canal but much smaller. 
This kind of instrument should be made of untem- 
pered steel, though some operators make them of 
whalebone to prevent breaking in the canal, — an un- 
necessary precaution, since no skilful operator would 
ever break off a low-tempered, well-polished, prop- 
erly-formed steel instrument of this kind. After a 
block is j)laced in the cavity the instrument is thrust 
in by its side, consolidating the gold to the side of the 
cavity. Thus the blocks are successively introduced 
and consolidated till the canal is filled. It is better 
so to arrange as to introduce the last portion of the 
gold near the centre of the canal, rather than at the 
side. The last blocks introduced should be stiff and 



326 



PULF-CAVITIES. 



dense, that they may be thrust in with considerable 
force. The method of filling canals at present em- 
ployed by many, is in the use of the filling instruments 
invented by Dr. Corydon Palmer, represented in Fig. 
95. There is a variety in size, and somewhat in form, 
so that in all positions they will readily enter the 
canals and effectually consolidate the gold, which is 




introduced in small cone-shaped pellets, loosely rolled 
so that they may be thoroughly condensed 

Another method of preparing; gold for filling roots, 
is to take the pure metal, and roll it down on a good 
rolling-mill as thin as possible, keeping it well an- 
nealed ; of this form the cones, and introduce them 
as already directed. Made in this way, they are 
stiffer, and fill up much more rapidly than when 
made of foil. They are to be condensed in the same 
manner. Where the canal has been formed with a 
tapered broach, it may be filled, with a gold wire, 



FILLING PULP-CANALS. 327 

made of the same size and taper of the broach ; this 
wire may be cut off at the orifice of the canal, or left 
protruding more or less into the decayed cavity, and 
be covered up with the filling. When a lost portion 
of the form of a tooth is to be restored, such pro- 
jecting wires may be made very valuable as anchor- 
ages. 

Some other substances have been thought quite as 
suitable for filling the roots of teeth as gold. Lead 
has been employed for this purpose ; but the principal 
difficulty with this is, to get it into such a condition 
as to be used with facility ; but, if as completely in- 
troduced, it would probably answer the purpose quite 
as well as gold. Dr. F. Peabody, about three years 
ago, described a method of filling the roots of teeth 
with lead, which his experience, as well as that of some 
others, seems to indicate in many cases at least is very 
good. It consists simply in forming the canal in the 
root slightly tapering from the pulp-chamber to its ter- 
mination ; then form from a lead rod a cylinder or cone 
of the same size and taper as the canal in the root ; 
let this be driven firmly to its place in the root ; the 
rod may now be cut off, leaving a slight projection 
from the entrance to the canal ; by this the orifice can 
be very perfectly closed ; then the pulp-chamber and 
cavity of decay may be filled in the usual manner. 
Tin foil is also used, and under favorable circumstances, 
with success. Gutta-percha,, dissolved in chloroform, 



328 PULP-CAVITIES. 

is used to some extent, and, it is claimed, with deci- 
dedly good results. It is prepared of such consistence 
as to be readily pumped into even the smallest canals 
by a little piston made by wrapping cotton upon a fine 
broach ; and, after having the canal prepared, it is 
filled by forcing the gutta-percha solution in with the 
appliance referred to. It is claimed that this method 
is equal to, if not superior, to any other, since by 
proper manipulation, every canal, however crooked, or 
small, can be completely filled ; the material will not 
be dissolved nor deteriorated ; and if there should be a 
slight protrusion through the end of the root, it would 
not irritate the tissue with which it would come in 
contact. Some experiments, too, have been made with 
plaster of Paris and similar substances, for filling 
roots and pulp-cavities, but with rather uncertain suc- 
cess — some claiming instances of success, and others 
reporting, in every instance, failure; so that there are 
not sufficient data to warrant the adoption of plaster 
or any similar substances in practice. 

In cases in which there is liability to irritation, the 
operation of filling a root is quite enough for one sit- 
ting ; and in any case, not more than three roots should 
be filled at one time. The filling of a large pulj>cav- 
ity will occupy one sitting, and that of the decayed 
cavity another. When a respite is thus had between 
the filling of the pulp-cavity and that of the decayed 
cavity, the former should be filled with Hill's stop- 



FILLING PULP-CANALS. 329 

ping or gutta-percha, so that no moisture may pene- 
trate it ; and then when the latter part of the filling 
is to be introduced, it will proceed as though there 
had been no interruption. From one to four days 
should intervene between the different divisions of the 
operation. The filling of the decayed cavity is to be 
performed according to the directions already given. 
When inflammation ensues after an operation of this 
kind, recourse is had to the treatment already de- 
scribed for preventing, counteracting, or reducing in- 
flammation. 

Some experiments have been made to test the effect 
of restoring the parts to health, forming a cicatrice 
at the point of the root, cleansing this out, filling 
the pulp-cavity and the cavity of decay, and leaving 
the canal unfilled ; and it is maintained that this 
method will, in favorable cases, answer the purpose 
quite as well as that of filling the root, and incur less 
risk. The treatment will be such as already described 
for the restoration of diseased roots ; all discharge 
through it must be suppressed, and all foreign sub- 
stances liable to decomposition removed from the canal, 
so that there may be a complete restoration before it 
is closed. 

Oftentimes, when a tooth has been filled without 
filling the roots and pulp-chamber, if the pulp be dead, 
or if the pulp afterward dies, the chamber becomes the 
receptacle of a very vitiated and acrid material, the 



330 PULP-CAVITIES. 

retention of which will almost invariably produce irri- 
tation. In all such cases, an opening should be made 
for the escape of the offensive matter. This is done, 
if the filling is not to be removed, by passing a small 
drill into the pulp-chamber or canal, just above the 
filling, as close as possible. The handle of the drill 
should be depressed, so as to give the opening a down- 
ward inclination from within outward, and thus favor 
the escape of any secretion. 

In the superior molars,, this opening may be made 
through the masticatory surface ; it may sometimes be 
in the depressions on the crown surface, even though 
there be no filling. In incisors, it is made through the 
palatine portion of the crown. It is better, however, 
in all cases, to make an opening, of this kind through 
the neck of the tooth, just under the free margin of the 
gum, since here foreign substances are not so liable to 
be crowded into it as where it is through the mastica- 
tory surface. In cases in which it is obvious at the time 
of filling the tooth that such an opening will be re- 
quired, it is better to make it before the filling is 
introduced, as follows : first, prepare the decayed and 
pulp-cavities for filling ; then drill through the neck 
of the tooth into the canal, to the extreme part of the 
pulp-chamber ; and finally introduce into this hole, 
its entire depth, a piece of smooth steel wire, such as 
will closely fit, leaving it exposed through the decayed 
cavity — and if it is not enough exposed when intro- 



DENTAL PERIOSTITIS. 331 

ducecl, the tooth-bone may be cut away about it, till it 
is fully exposed, when the decayed and pulp-cavities 
are filled in the usual manner, and condensed solidly 
against the wire. After the filling is finished,, the wire 
is withdrawn, leaving a smooth, continuous opening 
for the escape of any secretion that may collect within.. 
When the opening into the canal is not made till after 
the tooth is filled, there is liable to be a space between 
it and the filling that will receive and retain fetid mat- 
ter, which may become very offensive. This method 
of treatment is, however, always to be deprecated, and 
should never be employed except as a last resort, or 
in cases where it is impossible to command the time 
and opportunity for the proper treatment ; and even 
then it is better to make the opening and entrance into 
the chamber and canal just as though it were to 
receive immediate treatment; for in a great many 
instances the opportunity for that may soon occur. 

Dental Periostitis. 

This affection of the investing membrane of the 
roots of the teeth is of frequent occurrence after the 
death of the pulp, but rarely if ever before. Inflam- 
mation of this tissue, in its manifestation, is modified 
by the anatomical structure of the parts. . 

Whether there be two membranes in the alveolar 
sockets, the one lining the walls of these, and the other 



332 DENTAL PERIOSTITIS. 

investing the roots of the teeth, is not a matter of im- 
portance so far as the nature and treatment of this 
affection is concerned. This condition of the dental 
periosteum is induced by such irritating causes as would 
produce inflammation in other tissues. 

The first indication of approaching difficulty in this 
tissue is a sense of slight fulness, which invites con- 
tact, and even pressure from the opposing teeth— such 
pressure affording a rather pleasurable sensation and 
seeming relief. 

This condition is brought about by determination of 
blood to the part, and the surroundings being such as 
to prevent free expansion to the capillaries, and other 
small vessels ramifying this membrane, these walls 
are pressed upon in proportion to the force of this de- 
termination. 

This effort at expansion will occasion, especially in 
those teeth having very conical roots, quite a percep- 
tible elongation, and this more particularly occurs when 
active inflammation supervenes, which is the sequence 
of the state of irritation to which reference has just 
been made. 

After active inflammation has occurred, pressure or 
percussion upon the affected tooth usually causes great 
pain, — to such an extent that sometimes the slightest 
contact even by the tongue is intolerable. 

This condition varies much in degree in different 
cases, dependent largely upon the predisposition and 



DENTAL PERIOSTITIS. 333 

susceptibility to exciting causes of irritation and in- 
flammation, together with the character of these ex- 
citing causes, whether concentrated in action to a 
mere jDoint, or more extensive in their sphere of op- 
eration. 

Oftentimes only a very small portion of the perios- 
teum of a tooth will be affected ; it may be confined to 
the immediate vicinity of the point of the root, or to 
one side, or to the periosteum near the margin of the 
alveolus and the border of the gum. 

Indeed, so circumscribed is this affection often found, 
that the periosteum on one side of a root will pass 
through all the successive stages of inflammation to 
suppuration and destruction, without that upon the 
opposite side having undergone anything more than a 
slight irritation, if even that. In such cases the vital- 
ity has sufficient power to hold the disease at bay, and 
confine it to the immediate point of attack. 

When there is a systemic predisposition, the local 
exciting causes will sooner and more vigorously at- 
tack. Always when the pulp of a tooth is devital- 
ized, the periosteum is more liable to disease, and per- 
haps for several reasons. In almost all cases there 
are irritants at hand that did not exist before; and 
the periosteum is either enfeebled, and consequently 
less resistant, or the demand upon its function greater 
than before, in view of its being the medium of con- 
nection between the normally vital tissue and that 



334 DENTAL PERIOSTITIS. 

which is devitalized, or, at best, its life very much irn- 
|3aired ; and when the latter condition exists, the nour- 
ishment received by the cementum and dentine is 
wholly through the periosteum. In these facts doubt- 
less are to be found the cause of the greater suscepti- 
bility of the dental periosteum to disease after than 
before the death of the pulp. 

The exciting causes of this affection are to be found 
in the acrid debris of the dead and decaying pulps of 
the teeth, passing either in a fluid or gaseous state 
through the foramen at the point of the root, and there 
coming in contact with the periosteum, and in various 
deposits, calcareous and others, insinuated beneath the 
margin of the gum, encroaching upon and irritating 
the periosteum. 

It is also sometimes occasioned by an extension of 
disease from some other point. As an illustration of 
this, in susceptible cases, the periosteum of one tooth 
may become affected by the action of some local irri- 
tant, and two or more of its neighbors become affected 
by extension of the inflammation. 

Some medicinal agents act specifically upon the 
dental periosteum, inducing a very painful condition, 
thickening of the tissue, and elongation of the teeth. 

Mercurials present an illustration of this class of 
agents. The precise condition produced in the den- 
tal periosteum in mercurial ptyalism is perhaps not 
clearly comprehended. It is more than simple inflam- 



DENTAL PERIOSTITIS. 335 

mation. It is not modified or controlled by the same 
remedial treatment. It attacks the periosteum of liv- 
ing teeth as readily, and with quite as much violence, 
as of those which are devitalized. Alveolar abscess 
is not a common result of this affection of the perios- 
teum. 

Treatment. — The treatment of dental periostitis, in 
its details, will be governed by the attendant condi- 
tions, such as systemic predispositions, the vital force, 
and the local causes, and their peculiarities. 

Systemic treatment should have for its object the 
removal or counteracting of predispositions, and the 
abatement of the determination of blood to the part 
in question, by inviting it to other parts, by their 
stimulation, and by introducing into the system such 
agents as will tend to allay excitement in the affected 
part, and induce, so far as possible, an equilibrium 
of circulation throughout the system. 

The local treatment must also be wisely and faith- 
fully attended to. The principle applicable to the 
treatment of inflammation in any tissue is that to be 
employed here. It will be remembered, however, 
that there are many medicinal agents which possess 
very desirable properties that are still totally ineffi- 
cient, because of a want of adaptation. We have, 
however, at our command some very efficient reme- 
dial agents for the treatment of this affection, and the 
list is being constantly enlarged. 



336 DENTAL PERIOSTITIS. 

We propose here to consider rather the principles 
involved in the treatment than the details for special 
cases. 

The causes producing and influencing the disease 
should always be fully apprehended, immediately after 
which the following points should receive attention : 
First remove all irritants ; this will embrace the re- 
moval of the dead pulp, and all the debris from its 
chamber, and from the canal in the root or roots, and 
rendering them perfectly free from all offensive ma- 
terial, and keeping them so ; and the removal of all 
deposits that may be upon the teeth, especially those 
that may encroach upon the gum, or the alveolus and 
periosteum at or beyond the neck of the tooth ; also 
the removal of all injurious and useless teeth and roots 
in the vicinity. 

Secondly, relieve the congestion of the affected part, 
in some or all of the following ways : either by sys- 
temic influence, as already suggested, or by counter- 
irritation, j)roducing determination to a neighboring 
part, and thus relieving the affected part, or by de- 
pletion from the gum immediately opposite the seat of 
the affection. 

Counter-irritation may be effected by scarifying the 
gum, or by the application of some irritating agent, 
such as tincture of capsicum, tincture of iodine and 
cantharides. An excellent preparation of the latter, 
denominated cantharidal collodion, is very effective. 



DENTAL PERIOSTITIS. 337 

This preparation when applied to the gum acts 
promptly and efficiently in almost every case of acute 
dental j:)eriostitis ; it produces desquamation upon 
the surface of the mucous membrane where it is ap- 
plied. 

Counter-irritation may be produced, also, by mak- 
ing a deep incision in the gum opposite the tooth 
affected, and introducing a little flock of floss or cotton, 
saturated with creosote, which is to be kept in place 
till the inflammation of the periosteum is allayed, 
which will be effected in from one to five days. The 
silk or cotton should be changed every day till the 
restoration of the tooth to health is effected, when it 
is to be removed, and the wound permitted to heal. 
Mild stimulating ajDplications to the gums in the im- 
mediate vicinity, to increase the circulation, will in 
some cases be quite sufficient. A vapor bath, or warm 
water applied to the part, is often beneficial ; and in 
some cases a continued application of cold by means 
of ice-water, will arrest inflammation of the perios- 
teum. 

The tincture of aconite-root is a valuable local ap- 
plication. It is a powerful sedative and antiphlogistic 
remedy. This, with equal parts of tincture of opium 
and chloroform, constitutes a very valuable local rem- 
edy for periostitis. It may be applied by occasionally 
moistening the gum with it, or by placing on the 
gum, opposite the seat of the affection, a small pad 

22 



338 DENTAL PERIOSTITIS. 

of bibulous paper or lint moistened with the prepa- 
ration, which may remain from three to five minutes. 
This may be repeated as occasion may require; usu- 
ally, however, from one to three applications will be 
sufficient. 

Depletion with many is a favorite method of treat- 
ment, and is often productive of very good results. 
Two or three methods of accomplishing this are em- 
ployed. Simple scarification of the gum, cutting it 
more or less dee23ly, will secure sufficient haemor- 
rhage, especially if the gams are quite vascular ; when 
this fails, cupping, or the artificial leech, may be em- 
ployed; but the natural leech is the most efficient 
means of local depletion in this treatment; and every 
dentist should always have these at command, and be 
familiar with their use. The application of a leech, 
in very many cases, will in a short time subdue the 
most violent attack of acute periostitis. 

In the treatment of this affection, hypodermic in- 
jections give promise of most desirable results; for 
this purpose the solution of morphine or tincture of 
opium, from ten to twenty drops, may be injected, 
with a proper syringe, beneath the mucous mem- 
brane, when the pain will be found to subside in a 
few moments, and the severest symptoms be abated in 
a few hours. 

In * all cases of periostitis, the sooner it can be 
brought under proper treatment after the attack the 



ALVEOLAR ABSCESS, 339 

more easily will it be subdued. In cases of longer 
standing, where the affection has assumed a chronic 
form, the membrane more or less thickened and in- 
durated, and a persistent soreness of the tooth affected, 
heroic and persevering treatment will be required to 
overcome the difficulty ; in the great majority of cases, 
however, the result is the formation of alveolar ab- 
scess, rather than the condition just referred to, a 
description and treatment of which will next receive 
consideration. 

Alveolar Abscess. 

When inflammation occurs in the periosteum to the 
extent that the structural character of the tissue can 
no longer be maintained, then disintegration begins in 
it, and the surrounding tissue also, so far as it may 
be involved. When the condition arrives in which 
the life action ceases, the tissue at once begins to un- 
dergo solution, and, in addition to this, the pabulum 
or nutrient material, brought into the diseased terri- 
tory, is for the most part vitiated, its nutrient quality 
destroyed, and it is converted into debris, except that 
from it, under favorable circumstances, coagulated 
lymph is formed, which constitutes what has been so 
generally denominated the sac, and by some the pus- 
secreting sac, and by others the pyogenic membrane. 

Now, strictly, it is not any of these, but is simply 
a mass of coagulated lymph, varying in quantity, 



340 ALVEOLAR ABSCESS. 

when it exists at all, from a little shred or bleb, that is 
but little more than visible, to a mass as large as the 
tooth to which it is attached. As to its location, it 
varies; sometimes it is embraced by and fills up the 
space between the roots of the molars, either superior 
or inferior. In some cases it is merely an irregular 
mass attached to the end of the root about which the 
disease is ; in other cases it will cover a large part of 
the surface of the root or roots involved. The accom- 
panying illustration (Fig. 96) represents the position 

Fig. 96. 



of the lymph mass on the roots of different teeth. It 
will be more or less firmly attached, according to the 
extent of the disintegration of the periosteum, being 
less adherent when there is the greater destruction of 
the tissue. A portion will sometimes, upon the re- 
moval of the tooth, remain in the socket, with some 
attachment, though usually but slight, to the walls; 
this, however is not its usual place of lodgment and 
attachment. The density of this lymph mass varies 
in different cases. Sometimes it is quite dense, firm, 
and resistant; at other times so soft and flabby as 



ALVEOLAR ABSCESS. 341 

hardly to support its own weight. Now, that this 
substance is instrumental in, or has anything to do 
with secreting or forming pus, or the material dis- 
charged from an alveolar abscess, is not established nor 
warranted by deduction nor by fact. 

Now, the question occurs, what is the object of 
this product ? It may, in the first place, be regarded 
as an abortive effort for the repair of lost tissue, and, 
in the second place, the encystment of the disease- 
producing agent. Neither of these, however, can be 
accomplished. Repair cannot take place so long as 
the disease-producing agent is present ; and the char- 
acter of the agent or agents, and the anatomical struc- 
ture of the parts, preclude encystment. The local 
agents that occasion alveolar abscess may be in form 
either solid, soft-solid, fluid vapor or gas. Some of 
these could not be encysted in any anatomical struc- 
ture, and none of them can be in the tooth socket. 
This lymph mass is not only of no service in respect 
to reparation, but is a real obstacle to the proper ac- 
complishment of that process. This is fully recog- 
nized in all the j>roposed plans of remedy ; its remo- 
val is always regarded as an important factor in the 
treatment. 

The character of the discharge from alveolar ab- 
scess differs greatly in different cases, and somewhat 
at different periods of the same case. It sometimes 
consists of pure or laudable pus; this is of a yel- 



342 ALVEOLAR ABSCESS. 

lowish-white color, opaque, inodorous, sweetish taste, 
and of a creamy consistence. In the majority of 
cases it varies from this, however, exhibiting less the 
character of pus, with diminution of pus corpuscles, 
and an increase of vitiated ichorous fluid, in which 
sometimes pus-corpuscles are not found at all, with an 
acridity so great as to excoriate living tissue whenever 
it comes in contact with it. 

Usually when pure pus is secreted, coagulated 
lymph will be found most abundant; and, on the 
other hand, when a highly vitiated, acrid discharge is 
found, there will be almost, if not an entire absence 
of the lymph mass. 

The character of the discharge is modified by the 
systemic condition, by the tissue disintegrated, and 
by the character of the local irritants ; and it can only 
be changed by a modification of the first of these, and 
the removal of the latter. 

The size of the abscess cavity varies in different 
cases; in some it is quite small, involving a very 
little territory, in the immediate vicinity of the point 
of irritation ; in others it becomes enlarged, some- 
times to twice the size of the tooth about which it is. 
This difference arises from the varying severity of 
the disease, and the peculiar susceptibility of the 
parts. 

Usually the cavity has attained its full size before 
the evacuation of the pus;, and if this is benign, 



ALVEOLAR ABSCESS. 343 

little or no disintegration takes place afterward ; but 
it may be otherwise if the secretion is acrid. 

In an abscess rapidly formed, there is very con- 
siderable pressure by the contents upon the walls of 
the cavity while it is closed, and this is always the 
cause of pain, which in many instances is very severe. 
So soon as an opening is effected, and the tension re- 
lieved, the pain in a great measure ceases. 

There are various directions through which open- 
ings are made for the escape of the pus. Sometimes 
the discharge is through the root, sometimes from be- 
tween the tooth and alveolus, and at other times di- 
rectly through the alveolus and gum. There are 
occasional cases in which the discharge will be at a 
very considerable distance from the point of secretion ; 
but, in such cases, it always follows some natural ave- 
nue that affords a facility for its passage, as, for in- 
stance, along a suture. There are cases recorded where 
the issue from an abscess of the central incisor was 
near the posterior portion of the hard palate, and in 
these the channel of the pus lay along the suture of 
the palate bones. Sometimes the opening from an 
abscess of the first or second molar will be opposite 
the bicuspids on the buccal portion of the gum. Al- 
veolar abscess is exceedingly variable in character,, 
according to the constitutional peculiarities and sus- 
ceptibilities of the patient, the condition of the parts 
immediately adjacent, and, to some extent, the cause 



344 ALVEOLAR ABSCESS. 

which has produced it. In a good constitution, after 
an abscess is formed, it will discharge healthy pus. 
Occasionally, yet very seldom, does nature alone effect 
a permanent cure. In constitutions of a cachectic 
diathesis alveolar abscess is liable to constant discharge 
of an unhealthy pus, or purulent acrid matter, and 
the parts about it are usually in a diseased condi- 
tion. 

The cases in which alveolar abscess is most likely 
to occur are those of a manifest inflammatory dia- 
thesis, or those in which there is considerable local 
inflammation from some local exciting cause. In the 
cases of constitutional predisposition, the abscess after 
a time assumes a chronic character, constantly secreting 
and discharging jdus, but does not usually cause much 
pain, though the tooth from which it proceeds will 
experience some soreness and an uneasy sensation. 
In the acute forms of it, however, there will be intense 
pain. In some cases an abscess will be formed with- 
out much irritation of the surrounding parts, while 
in others, irritation and inflammation will extend to 
parts more remote, especially if there are active irri- 
tating agents at work. 

Treatment. — The treatment of alveolar abscess will 
be governed by the constitution of the patient and 
the condition of the part affected ; a case of recent 
origin will yield much more readily than one of long 
standing. When a case has assumed the chronic 



TREATMENT OF ALVEOLAR ABSCESS. 345 

form, and the surrounding parts have become impli- 
cated in the diseased condition, a restoration to health 
is often very difficult. In the earlier periods of the 
profession, the removal of alveolar abscess was thought 
to be, as a general thing, wholly impracticable. But 
by the treatment now employed this affection is 
readily eradicated, unless the parts in the immediate 
vicinity are very much involved. In some cases the 
accumulation of coagulated lymph and debris on the 
point of the root is very large, and absorption has 
taken place to accommodate it; in such instances, this 
being destroyed, the space occupied by it will be filled 
up with a healthy tissue. In young persons, when 
an abscess is formed on the point of a root, especially 
in the single-root teeth of the superior maxilla, the 
discharge is frequently through the tooth in conse- 
quence of the large size of the foramen at the point 
of the root, and generally, in such cases, the local 
treatment may be made through the canal. Sometimes 
the discharge is between the root and the wall of the 
alveolus. More often, however, especially in persons 
after complete development, the discharge is through 
the alveolus and the soft parts to the surface, by the 
shortest course. 

When an alveolar abscess is influenced by any con- 
stitutional derangement, general treatment must be 
resorted to, such as the condition indicates. The local 
treatment always demanded is such as will break up 



346 ALVEOLAR ABSCESS. 

and destroy the accumulated lymph mass. This is 
effected either by surgical or therapeutic treatment, 
and frequently, in chronic cases, by both together, but 
in the great majority of acute cases therapeutic treat- 
ment alone will be sufficient. In order to break up 
an abscess by an operation it must be easy of access; 
and it is very seldom that an operation of this kind 
can be performed through the root of a tooth; but, 
fortunately, in almost all those cases where the dis- 
charge is through the root, therapeutic treatment alone 
will answer the purpose. When the point of discharge 
is on the gum opposite the accumulation on the root, a 
sharp-pointed bistoury may be used, and the canal of 
discharge sufficiently opened to admit the free use of 
the instrument at the seat of the disease. Then the 
lymph mass should be dissected from the point of the 
root and removed as completely as possible. After 
this, if the case is a favorable one, nature may be left 
to accomplish the work, in which case the detached 
material will be thrown off, healthy granulations de- 
veloped, and the parts restored to complete health. In 
other cases, however, after an operation, nature unaided 
will not complete the cure, but such therapeutic treat- 
ment must be resorted to as the circumstances seem to 
require. In some cases the opening through the al- 
veolus will require to be enlarged, and this part of the 
operation requires great care. All loose particles of 
bone should be removed from the opening, since, if 



TREATMENT OF ALVEOLAR ABSCESS. 347 

permitted to remain, they would produce irritation 
and tend to increase the difficulty. 

When the therapeutic treatment is applied through 
the root, the canal is to be cleansed of all foreign and 
detached matter, and opened freely through to the 
point ; and if the discharge is fetid, some disinfectant 
and antiseptic should be used. The cleansing of the 
root may be accomplished by injection of chloride of 
sodium ; after which the agent to act on the disease at 
its seat is to be introduced. There are a number of 
agents used for this purpose, the chief of which are 
salicylic acid, chloride of zinc, nitrate of silver, and 
creosote, the first being applied in the solid and the 
others in the liquid state — though the nitrate may be 
employed in the solid form. After this, during two or 
three days, floss silk, moistened with a mild solution 
of creosote and tannin, in alcohol, should be applied 
daily ; and then clean silk or cotton may be worn in 
the canal, changed every day, for three or four days, 
or till it is manifest that there is no longer any dis- 
charge, and that the- parts are in a healthy condition. 
If nitrate of silver, in solution, or creosote, is used, a 
piece of floss silk should be moistened with it, and 
passed through the root in the manner already de- 
scribed. The nitrate is more prompt in action than 
creosote, and will accomplish a specific object in a 
shorter time. Either of these solutions may, by the 
use of the syringe,, be very effectively thrown through 



348 ALVEOLAR ABSCESS. 

a root in the following manner : Fill the orifice of the 
canal with gutta-percha ; drill through it a hole large 
enough to receive tightly the point of the syringe ; and 
then, charging with the solution, inject it through the 
root ; in cases where there is an opening through the 
gum, the injection may be forced round through this. 
The condition of the parts will indicate how long this 
kind of treatment should continue. Ordinarily, when 
the discharge is entirely through the gum, the bistoury 
should be used to enlarge the opening; or in some 
cases it is preferable to use the " sea-tangle " tent ; for 
this purpose form a plug of this material, in size to fit 
closely into the fistulous opening, where it should be 
placed and remain for twenty-four to forty-eight hours. 
When saturated with moisture, the tent expands to 
more than double its size when in the dry state. Care 
should be exercised lest too much irritation is produced 
by the pressure ; this, however, can be easily regulated. 
In many cases therapeutic treatment alone will accom- 
plish the object; and when the opening is large and 
direct, the therapeutic agents may be introduced 
through it directly to the seat of disease. If nitrate of 
silver, in solution, or creosote, is used, it should be in- 
troduced to the point of affection on a pledget of cotton 
or floss silk, as heretofore directed ; or if, as is prefer- 
able, chloride of zinc or nitrate of silver in solid, it 
should be passed through the opening into the main 



TEEATMENT OP ALVEOLAR ABSCESS. 349 

cavity. This treatment should be kept up till the in- 
dications are fulfilled. 

In the treatment of abscess of the inferior maxilla, 
much difficulty is often experienced from a want of 
free egress for the pus and debris. While, in the supe- 
rior teeth, the pus may frequently escape through the 
tooth by gravitation, this force in the inferior jaw in- 
creases the difficulty. The secretion being made at 
the bottom of the socket, it remains there, and is fre- 
quently pent up till it finds an outlet through the gum, 
somewhere between the point of the root and the neck 
of the tooth. It is in many instances very difficult to 
get an opening as low down as the point of the root, 
since the buccal attachment to the gum is usually quite 
above that point, particularly in the case of the molars 
and bicuspids. Very seldom, if ever, can the coagu- 
lated lymph on the root of an inferior tooth be de- 
stroyed by treatment applied through the canal of the 
root. Some are accustomed to make a vertical incision 
of the gum, as low as the point of the root, and perfo- 
rate the alveolus, and treat through this channel, 
as already described. Owing to the disadvantage 
above mentioned, much more energetic treatment is 
necessary to attain success with an abscess of the infe- 
rior than with that of the superior teeth. 

In the majority of cases, where one-half or more of 
the periosteum of a root is involved in abscess, the in- 
dications are generally supposed to point to the re- 



350 ALVEOLAR ABSCESS. 

moval of the tooth. In the lower teeth, a very serious 
difficulty occasionally occurs from abscess, namely, an 
external opening and discharge; and in all cases 
where this condition has already been reached, the of- 
fending tooth should be removed. But when such a 
result is only anticipated, and is yet contingent, treat- 
ment may be employed to avert it ; and in order to do 
this, a deep and free incision should be made in the 
gum, opposite the affected tooth, and jwultices applied 
within; and where there is external swelling, pressure 
is recommended, as follows : Adjust a piece of thick 
sheet-lead to the part, and make the pressure on this 
by means of a bandage embracing it and passing round 
the head. It is supposed that this application coun- 
teracts the gravitation of the secretion, pressing it up- 
ward, and thus inducing it to seek an outlet at some 
more desirable point. 

In many cases the most prompt and efficient treat- 
ment consists in the extraction of the tooth involved 
by the abscess. This should be carefully done, that 
there may be no fracture of the alveolus, and no 
laceration of the gum. After the tooth is removed 
it should receive the following treatment: Remove 
from the root or roots, with the proper instrument, all 
coagulated lymph, diseased periosteum, and any foreign 
substance that may be present. The cavity of decay, 
if one exists, the pulp-chamber, and canal in the root 
or roots, should all be perfectly cleansed, formed, and 



TREATMENT OF ALVEOLAR ABSCESS. 351 

filled permanently. This will occupy from thirty to 
sixty minutes. This part of the work should proceed 
as rapidly as is consistent with thoroughness. Imme- 
diately after the removal of the tooth there should be 
placed in the socket from which it was removed a 
pledget of cotton, moistened with some preparation 
that would be acceptable to the part, and that will 
prevent, so far as may be, the coagulation of the blood 
while the tooth is out of the socket. For this pur- 
pose the tincture or the infusion of calendula (mari- 
gold) has been used, and also hamamelis virginica 
(witch hazel) extract ; both of these have been used 
with good results. Some, however, prefer to use noth- 
ing of the kind for this purpose, but rather permit the 
blood to coagulate in the socket, and remove just be- 
fore inserting the tooth. 

The tooth having been prepared as above described, 
should now be carefully replaced in its socket, the 
jaws should then be closed firmly, which will carry the 
tooth to its precise position. Ordinarily, no stays or 
ligatures will be required to hold it in position. 

Just previous to the replacement the pledget of cot- 
ton will be removed, and any debris that may be found, 
clots of blood, and, indeed, any and every thing that 
does not properly belong to the part as living struc- 
ture, should be taken away. Usually, the tooth will 
become firmly attached within a few days. This mode 
of treatment is practicable even when a fistulous open- 



352 ALVEOLAR ABSCESS. 

ing has been formed through the cheek to the external 
surface. 

In regard to the treatment of alveolar abscess, 
much vet remains to be learned. With the attain- 
ments thus far made in this direction, no aspiring 
dentist will rest satisfied, though in the hands of a 
few it has made great progress within a very recent 
period. 

In a treatise of this character it is impracticable to 
enter into the details of the pathology of this affection, 
or, very minutely into the rationale of its treatment. 
A thorough knowledge of these involves a wide range 
of pathological knowledge. 



CHAPTER X. 



PIVOT TEETH. 



Whenever the crowns of the anterior teeth have 
become so much decayed that they cannot by filling 
be rendered useful, they may, under favorable cir- 
cumstances, be sujyplied by artificial crowns con- 
structed on the roots. For the successful accom- 
plishment of this work, the following conditions are 
important: 

First. The constitution of the patient should be 
good. 

Second. The mouth should be in a healthy condi- 
tion and without diseased teeth or roots. 

Third. The teeth should be free from calcareous 
deposits, and from all foreign substances liable to in- 
duce irritation or inflammation. 

Fourth. The attachment of the teeth should be 
perfect and healthy. 

Fifth. A root having a living, healthy pulp is to be 
preferred to one the pulp of which has been dead for 
some time. 

Sixth. The root above the neck should be sound. 

Seventh. The root should occupy a correct position 

23 



354 PIVOT TEETH. 

in the arch. Prior constitutional treatment will often 
be required where there are unfavorable conditions. 

The roots of the six superior anterior teeth are 
better adapted for the reception of artificial crowns 
than those of any other in the mouth. The roots of 
the first bicuspids frequently terminate in two points, 
and are always more or less compressed, so that they 
will not receive a pivot large enough to sustain a 
crown ; besides, these teeth are masticatory, and crowns 
23ivoted to them very soon become loose and useless. 
The roots of the inferior incisors are also compressed, 
and thus subject to the same disability. Occasionally, 
however, pivot crowns are attached to the roots of the 
superior bicuspids, and the inferior incisors, cuspids, 
and bicuspids. But, in order that such an operation 
shall be of any utility, the conditions must be favor- 
able, the roots with as little lateral compression as pos- 
sible, in a very sound and healthy state, and without 
any tendency to inflammation. 

The preparation of the root for the reception of an 
artificial crown is a very simple process. It will, 
however, be somewhat modified by the kind of crown 
used, and the method of attaching it. Ordinarily, 
the first step is to remove the natural crown or any 
remaining portion of it, with a fine saw or excising 
forceps. Of this latter instrument there are various 
forms, that in most common use having narrow trans- 
verse edges, closing squarely together, as represented 



PIVOT TEETH. 



355 



in Fig. 97. With these forceps any broken fragments 
of the crown can be readily removed. In every case 
in which an artificial crown is required, the natural 
crown is very much decayed, and in this condition is 
very readily removed with excising forceps, nipping it 

Fig. 97. 




off in fragments, beginning where it is weakest and 
thinnest, and thus removing it by piecemeal — at least 
as far as the forceps are available. Yet care is neces- 
sary, even in this manner of using the forceps, lest 
the root be fractured or too much jarred. 

Fig. 98. 




After such excision with the forceps, the root is to 
be dressed down for the reception of the crown with a 
round, or, better, an elliptical file. But for this opera- 
tion of removing a crown a very fine, smooth, narrow 
saw, set in a frame (Fig. 98), is, in some respects, 



356 PIVOT TEETH. 

preferable to the forceps, it being less liable to injure 
the root than the latter. With this the crown is sawed 
off at the margin of the gum, leaving the end of the 
root about the form required for the reception of the 
artificial crown. In the process, the crown being sus- 
tained by the fingers, the saw, kept constantly wet, is 
applied to the tooth, and passed along its proximate 
side to the margin of the gum, and then along this 
through it, cutting it off at right angles with its axis. 
After the crown has been thus cut off, the root is fitted 
with a fine, round file for the artificial crown, and, or- 
dinarily, it should be dressed at a right angle with its 
axis. 

At this stage of the work, if the pulp remains alive, 
it should be removed, and the preferable method is by 
direct operation, in the manner already described (pp. 
304-5) . It is better in all such cases to avoid the use 
of arsenic for the destruction of the pulp ; it will often 
be necessary to destroy it before the crown is removed. 
For a successful operation it is always preferable that 
the root have the pulp living. After it is removed, 
the canal is to be enlarged to a suitable size, with the 
appropriate drill. If there is any remaining sensi- 
tiveness of the dentine, as is very seldom the case, the 
bur drill may be used for this purpose; but if not, 
then the common spear-pointed drill will be best. 
Where, however, the canal takes the form of a mere 
fissure, either the bur drill or the four-sided broach 



FITTING THE CJROWN. 357 

may be employed. The depth to which the canal 
should be enlarged will be determined by the length 
of the root, but it should, in all cases, be sufficient 
rirroly to retain a pivot, which is from one to two 
lines : and the diameter of the hole will be determined 
by the size of the root. The drills should be frequently 
moistened with water to prevent their clogging. The 
shaft of the instrument in the operation should be in 
a line with the cutting edges of the two adjoining 
teeth, and midway between them, and the drill it- 
self should follow the natural canal as nearly as pos- 
sible. 

Fitting the Ceowx. 

The tooth selected should be of a size, shape, and 
color to correspond with the natural crown which it is 
to represent. It should not be ground on the sides or 
point, and. according to general opinion, ought not to 
•; ached with the emery-wheel. A different opinion, 
however, is entertained by some, who suggest the 
o-rindino- of the entire anterior surface of the artificial 
crown, thus removing the vitrified surface of the en- 
amel, after which it should be well polished with fine 
stones and emery, by which it is claimed that the ap- 
pearance corresponds much better with that of the 
natural teeth, which in many cases, at least, is correct. 
The diameter of the neck of the crown should corre- 
spond with that of the articulating surface of the root 



358 PIVOT TEETH, 

to which it is to be attached. In fitting the crown to 
the root the joint should be made as nearly perfect as 
possible, for the tooth is thus more permanent and 
comfortable ; an open joint offers a receptacle for the 
lodgment of food and other foreign substances, where 
they become vitiated and produce unpleasant if not in- 
jurious effects. The crown may be principally fitted 
to the root without a pivot by dressing the latter with 
a round or elliptical file, and frequently trying the 
crown on in its proper position. After having been 
thus pretty accurately fitted, a trying pivot of soft 
wood should be introduced, by means of which, grind- 
ing it to its exact form, the crown may be fitted to the 
root in its proper position. 

For fitting pivot teeth Dr. E. Townsend invented 
a round file, with a counterpart, into which the file 
exactly fits; with the former of these the root is 
dressed, and with the latter the articulating surface 
of the crown. This apparatus would be good were it 
not for the great difficulty of dressing porcelain teeth 
with a file. By care, a very complete fit can be made 
with a round file alone. Some coloring material, as 
rose pink, for instance, may be put on the base of the 
crown, and then the tooth, with the pivot inserted, 
set in its place, when the root will be marked where 
the crown has touched it, and this can be dressed 
at the point of contact. This operation is repeated 
till a perfect fit is obtained. This method is to be 



ATTACHMENT OF THE CROWN. 359 

recommended to those who have had but little ex- 
perience in adjusting pivot teeth. 

Another method of making an articulation is, to 
dress the root as first described, then take an impres- 
sion of the part in plaster of Paris, and from this get 
a model upon which to fit the crown. This method, 
however is advisable only in cases where it is desirable 
to avoid annoyance to the patient by a tedious fitting 
process. 

Attachment of the Crown. 

The means of attachment in most common use, till 
recently at least, is that of wood pivots ; for these 
wood in the natural condition was formerly employed, 
but it is now compressed. The kind best adapted for 
pivots is the fine-grain, tough, slow-growth hickory, 
of straight, uniform fibre, which should be thoroughly 
seasoned. For its preparation, take blocks six or eight 
inches long, and split them into rods about one-fourth 
of an inch square ; then, with a knife and file dress 
them down to a size one-third greater than that of the 
intended pivots; afterward, pass them through three 
or four holes of the ordinary drawplate inverted, thus 
making them of uniform thickness throughout ; and, 
finally, turning the drawplate, pass them through it in 
the same manner as wire, continuing till the rods are 
of proper size, and all the pores of the wood are closed 
by compression. They should be slightly oiled before 



360 PIYOT TEETH. 

being drawn through the plate. They may be drawn 
so as just to fit the holes of the artificial crowns, being, 
of course, of different sizes. Pivots thus compressed 
are stiffer, stronger, and far more durable, and there 
being greater density of fibre there is less absorption 
of moisture, less expansion, and less liability to decay 
than in wood in the natural condition. 

In arranging the crown in position, care is necessary 
to jjr event it from being struck by the teeth of the oppos- 
ing jaw, especially, since it often happens, where the 
natural crown has been absent for some time, that the 
corresponding tooth of the lower jaw becomes some- 
what elongated, and strikes forcibly against a properly 
adjusted pivot tooth. Such a difficulty is met either 
by filing off the elongated tooth, or, by grinding out 
the palatal portion of the artificial crown sufficiently 
to accommodate the elongation. The former is the 
better method, and should always be adopted when in- 
flammation of the dentine, exposure of the pulp, or an 
irritable condition of the surrounding parts do not 
forbid it; though, in many instances, both methods 
may be advantageously employed. But, by some means, 
the antagonizing teeth should always be prevented 
from coming in contact with the artificial crown ; and 
this latter should never press against the tooth on 
either side of it ; indeed, it is better that there be a 
small space on, each side. 

When the crown is in its proper position, the hole 



ATTACHMENT OF THE CROWN. 361 

in the root and that in the crown do not always have 
precisely the same direction; in which case, a pivot 
will be required having a curvature according to the 
variation ; and the extent and direction of such inflec- 
tion should be carefully observed while adjusting the 
crown with the trying pivot. The pivot is to be neatly 
and accurately fitted into the crown first, and then the 
length of it required for the root ascertained with the 

Fig. 99.. 




gauge represented in Fig. 99. This gauge consists 
of a wire of a size freely to enter the pivot-hole, hav- 
ing a little slide with a flange attached. By introdu- 
cing this wire into the pivot-hole, the slide is pressed 
back, and the depth of the hole indicated at once. The 
pivot is then cut off accordingly and dressed to the 
proper size and inclination, and gently pressed to its 
place with the thumb and finger. Before being intro- 
duced, however, it may be wrapped with gold foil, 
which will serve to protect the dentine of the root from 
decay, and also to preserve the pivot. Two or three 
thicknesses of No. 6 gold foil may be placed between 
the crown and the root, so as to make a more perfect 
joint and exclude the moisture. There is, however, 
not much advantage in this. A thin sheet of Hill's 
stopping, placed in the joint, makes a better adaptation 



362 PIVOT TEETH. 

than the gold, and os artificial may be used for the 
same purpose, and in many instances is far better than 
either Hill's stopping or gold ; the canal in the root 
above the pivot should be filled with gold, or some 
appropriate material, though in cases where there is a 
discharge through the root, this would not be admis- 
sible. 

The canal at the orifice is sometimes considerably 
enlarged by decay, so that when the crown is fitted 
and the canal sufficiently opened for the reception of 
the pivot, there will be a cone-shaped space which the 
ordinary pivot will not fill. There are several methods 
of obviating this difficulty ; one of these is, completely 
to fill the enlargement with gold, and then perforate 
this filling with the proper-sized drill for the reception 
of the pivot ; or, which is better, to introduce into the 
canal a polished steel wire of the size of the intended 
pivot ; round this consolidate a filling of gold, having 
first made retaining-points at the proper places in the 
dentine ; finish perfectly flush with the end of the 
root ; and then withdraw the wire from the canal, and 
it is ready to receive the pivot with the crown attached. 
Some operators form the wood pivot of such a shape 
as to fit into and fill the enlarged cavity. Another 
method is, after the pivot is fastened into the crown, 
to build round it, on the base of this, a portion of 
Hill's stopping, of about the size and form of the en- 
largement in the canal ; and then the tooth being 



METALLIC PIVOTS. 363 

ready to insert, soften the stopping by heat, and in- 
troduce it carefully into place. The os artificial in 
such cases is still better. 

It frequently happens, in cases where the pulp has 
been dead for a considerable time, that there is more 
or less discharge through the canal of the root, and a 
tooth is required immediately, or at least before there 
is time for treatment to abate the discharge. To 
such a condition some arrangement must be adapted 
so as not entirely to close up the canal, and preclude 
the escape of pus. For this purpose a groove may be 
cut along the wall of the canal, or, perhaps better, on 
the side of the pivot throughout its length, for the dis- 
charge of the secretion.. Where there is irritation or 
liability to inflammation, a temporary pivot of soft wood 
or of hard wood loosely fitted, should be worn ; for thus 
the root is less jarred by percussion on the crown, and, 
if need be, the crown and pivot can be removed. 

Metallic Pivots. 

The liability of a pivot of wood to wear off at the 
point between the crown and the root, as well as to be- 
come offensive, and the difficulty of removing the tooth, 
have led dentists to seek some less objectionable mate- 
rial ; and metals have been experimented upon, and 
found in some respects preferable. Gold has been em- 
ployed for this purpose more than any other metal. 



364 PIVOT TEETH. 

Pivots made of this do not become offensive, do not 
wear off, and admit of any desired curve, and of an 
easy removal of the crown. There are several methods 
of attaching this kind of pivot to a tooth, and a very 
common one is, to fit into the hole in the crown a piece 
of pivot wood ; cut it off even with the base of the 
crown, and perforate it with the proper-sized drill for 
the reception of the metal pivot, which may be rough- 
ened or barbed on its sides, and then forced into the 
place prepared for it. Another method is to drill into 
a block of wood ; insert the pivot, prepared as above, 
then dress down the wood round it till this will fit 
closely into the crown ; and after it is pressed in, cut 
off the protruding portion of wood. In either of these 
methods, when the wood becomes moist, the metal pivot 
will be very firmly retained. This pivot may also be 
attached to the crown by soldering. Place the edge 
of the tooth in plaster of Paris ; set the pivot in its 
proper position in it ; fill round this with fragments 
of gold plate, and put on solder and borax ; heat up 
with a blow-pipe, and draw the solder to the bottom 
of the cavity. Another method, sufficient for all 
practical purposes, is to set the pivot in place, and 
pack round it a stiff amalgam of gold and mercury ; 
evaporate the mercury by heat. A better method 
than any of these is to have teeth manufactured with 
a platinum tube inserted, into which the pivot can be 



METALLIC PIVOTS. 365 

soldered. Pivots may also be attached to the ordinary- 
plate teeth. 

For attaching the metal pivot to the root, it is some- 
times fitted tightly to the canal, and introduced into 
it without any other substance. This is objectionable 
on account of the wearing of the root, certain to take 
place if there is the least jarring or moving of the 
crown. To obviate this, various methods have been 
devised, one of which is to wind floss silk about the 
pivot before introducing it ; but this soon becomes of- 
fensive, and requires frequent renewal. Another me- 
thod is to introduce a piece of wood into the root, and 
drill through it for the reception of the pivot, which 
is squared and roughened, — squared to prevent it from 
turning round, and roughened to secure it from draw- 
ing out. But if it is desirable to remove the tooth 
occasionally, the pivot should not be barbed. 

Metal tubes may be introduced into the roots for the 
reception of the pivots. These tubes are made of hol- 
low gold wire of projjer size, the method of prepar- 
ing which is, to take a piece of No. 30 gold plate, 
from four to six inches long, and from a third to a 
half inch wide, and bend it round a piece of smooth 
polished steel wire of the size of the intended pivot ; 
draw both together through a drawplate, down to one 
size larger than the hole in the root ; then take out 
the wire, and solder up the tube ; on it cut a fine 
thread with a screw-plate ; from it cut off a half to 



366 PIVOT TEETH. 

three fourths of an inch in length, and insert into 
this a piece of wire it was drawn upon ; grasping 
this section with a small vice or pair of nippers, screw 
it carefully into the root ; and having introduced it 
far enough, withdraw the piece of wire, cut off the 
protruding piece of tube with a fine saw then file and 
neatly polish. The root is thus ready for the recep- 
tion of the crown, the pivot of which should fit very 
accurately into the tube. A very slight curvature of 
the pivot will enable it to retain a very firm hold in 
the tube. The tube's inner end may be soldered up 
if desirable ; and if there is decay at the orifice of 
the canal, a flange may be soldered on to its outer end, 
flush with the end of the root, and the decayed cav- 
ity filled beneath it, the flange serving to retain the 
filling perfectly in place. These tubes can be best fit- 
ted in with the screw, though they are sometimes 
placed in without this, and gold foil packed about 
them to retain them. They may be made to receive a 
square pivot, by being drawn, in their manufacture, 
on a square wire instead of a round one. For the es- 
cape of pus, as already referred to, the pivot may be 
made of hollow wire, with a hole through the crown 
of the tooth. 

A plate tooth, with a metallic pivot attached, may 
be used instead of the ordinary pivot tooth ; and it 
is in some cases required, on account of the manner 
in which the teeth antagonize. But in all cases where 



METALLIC PIVOTS. 367 

a plate tooth is used, it should have a metallic base to 
rest on, and cover the end of the root. Properly to 
construct this, an impression must be obtained, and 
models and counter-models made, and the base swaged; 
and then to this the pivot and tooth are attached. 
Irregularity of the teeth, and especially of the root 
on which the crown is to rest, may require a peculiar 
adjustment of the pivot, which may be very easily 
effected by the method just referred to. 

Occasionally, bad consequences follow the opera- 
tion of inserting a pivot tooth, the most frequent of 
which is inflammation of the joeriosteum. Rough 
manipulation is very liable to induce this condition, 
where there is an inflammatory diathesis, in which 
case too great care cannot be recommended; and 
prior treatment will sometimes be advantageous. After 
periostitis has supervened, either constitutional or local 
treatment, or both may be employed, — constitutional, 
by emetics and saline cathartics, and, indeed, any agent 
that will equalize the circulation and counteract the 
inflammation ; and local, by the same means as already 
prescribed for periostitis elsewhere; in addition to 
which, it may sometimes be necessary to remove the 
crown and pivot from the root. It is always impor- 
tant to commence the treatment of such cases at the 
first indications of the disease. 

Sometimes, even with considerable care, a crown 
will be split by the introduction or the expansion of 



368 PIVOT TEETH. 

the pivot, in which case, of course, another tooth must 
be selected. When a pivot breaks off, and a portion 
adheres in the root, this may be drawn out with pliers, 
or a pivot extractor, or, if it does not protrude enough 
for this, it may be drilled out. A root is sometimes 
split by the expansion of a tightly-fitting pivot, or by 
a blow on the crown of the tooth ; and when this hap- 
pens, it must be removed, since it cannot be made 
longer to retain a tooth. Pivot teeth should seldom, 
if ever, be worn in a mouth in which teeth on plate 
are worn. They are now far less frequently worn 
than formerly, because, perhaps, of the improved me- 
thod of inserting teeth on plate. Under favorable 
circumstances, however, they may be worn with great 
comfort and usefulness from five to fifteen years. 

Other methods of making and attaching substitutes 
for the crowns of the natural teeth have been devised 
and brought into quite general use since the third edi- 
tion of this work was issued. 

These have greatly increased the range of useful- 
ness of artificial crowns. They are constructed and 
applied with about equal facility to the roots of all 
classes of teeth, thus making the roots of much more 
importance and value than they were formerly sup- 
posed to possess. 

Considering the use which they may now be made to 
serve, it may wellnigh be regarded as criminal to ex- 
tract sound healthy roots. 



METALLIC CROWNS. 369 

The first plan of restoration to which reference is 
now made, is that denominated the "Richmond crown," 
from the name of him who claims to have invented it. 
The plan consists in the construction of a gold crown 
in about the following manner: From plate, if gold, 
twenty-two carats fine, and in thickness about thirty, 
Stub's gauge, cut a band or strip equal in width to 
the length of the proposed crown ; then get the exact 
circumference of the cervical part of the root upon 
which the crown is to be placed ; then make the gold 
band to correspond in length to the circumference al- 
ready obtained, and bend it into a ring, shaping it as 
nearly to the form of the end of the root as may be ; 
place the ends squarely together and solder; then 
adapt and fit to the end of the root, so it may be 
pressed or driven on and retain its position with a good 
degree of fixedness. Now remove the band and solder 
upon its crown end a heavy plate; upon this should 
be soldered three or four little globules of gold, if for 
a molar, or if a bicuspid, two, to constitute the cusps 
of the crown. The crown surface thus formed can be 
trimmed and dressed with the burs and corundum 
cones to any particular form indicated. A better 
method of preparing the crown plate is to use pure 
gold plate, No. 30, Stub's gauge; then, with dies made 
from the impressions of well-formed teeth of the same 
class, stamp the plate, giving it the exact form of the 
masticating surface of a natural tooth of the class in 

24 



370 PIVOT TEETH. 

hand. This cap should have its inner depressions 
filled with fine gold solder, then fit and solder the cap 
to the band already described, and proceed with the 
insertion as by the other plan. Having the crown 
thus formed, it is ready for insertion. The root is 
next to be prepared, if not already done ; indeed, 
in most cases, where circumstances will permit, it is 
proper, and perhaps best, to first prepare the root. If 
this has irritation or disease about it, or a discharge 
through it, restoration to a healthy condition must 
first be effected, and especially if there is discharge 
through the root must it be arrested. After these 
things are accomplished, any protruding portions of 
the root that would prevent the proper adjustment 
of the crown should be removed; the canal should 
be thoroughly cleansed, disinfected, and the remote or 
inner third, or even half, of the canal completely filled 
with some appropriate material. Suggestions upon 
this subject given on page 362 of this work are perti- 
nent here. Into the outer and unfilled part of the canal 
may be fixed a screw; this may be of gold, platinum, 
or steel ; the latter, in some respects, is better than 
either of the others ; it can be obtained already made, 
of the right size and form, and is stronger than either 
gold or platinum. The screw, when fixed in place, 
should be of such size and length as to admit the 
crown to its proper position. The next and final step 
in the work, if all things have been well done to this 



METALLIC CROWNS. 371 

point, is to place on the end of the root, about the 
screw, a small portion of oxyphosphate or oxychloiide 
of zinc, and a sufficient amount in the crown that the 
space is completely occupied when the crown is forced 
to its proper place. It is not always an easy matter to 
decide as to the requisite amount of plastic material; 
too small a quantity will occasion a space beneath the 
crown, and endanger the strength and permanence 
of the work, and an excess will prevent the crown from 
taking its proper position. To meet this difficulty the 
practice of some is to drill a hole through the crown- 
surface of the tooth sufficient in size for the escape of 
the excess of the plastic filling, always using enough to 
certainly fill the space, and afterward filling the hole 
with gold foil or with a screw. The crown should be 
finished, and its adaptation made to the tooth of the 
opposite jaw, before the final setting. They may be 
made of gold or platinum. 

Another method is, after having prepared the root 
as described above, to put the ring or band, without its 
crown cap, firmly on the root, and fill completely with 
the plastic filling ; after this has become perfectly hard- 
ened, it may be cut down and formed properly, and 
the masticating surface made by filling and building 
with gold foil. 

Another plan is to form the crown cap as described, 
and, after fitting, instead of soldering it to the band, 
solder to its inner side one or two little staples, loops, 



372 PIVOT TEETH. 

or pins, that shall serve as anchorages, then, when 
the plastic material is introduced and still soft, place 
the cap in its position with the anchorage loops well 
imbedded in the plastic filling ; after this has set 
the operation is about complete, except, perhaps, a 
little dressing and finishing. In all cases the border 
of the band that passes beneath the free margin of 
the gum should be brought to a thin edge before it is 
put on, and when in place should fit the root very per- 
fectly ; it should also extend nearly or quite to the 
line of attachment of the gum to the root. 

These crowns of gold, though practicable for the 
molars, and, in many cases, the second bicuspid, and, 
in a few cases, for the first bicuspid, are not admissible 
for the six anterior teeth, either superior or inferior. 
But the principle is applicable for these, the process 
being about the same as that described, except that a 
porcelain facing, representing the external face of the 
tooth, is set into the band, which is cut away for its 
reception and adaptation to the root; an ordinary thin, 
plain plate tooth serves the purpose- well. After being 
properly adjusted, it should be lined and soldered 
firmly to the band, the two thus joined constituting 
the crown to be inserted. The palatine part may be 
covered with gold, and formed to the shape of the 
palatine surface of the natural tooth. The crown thus 
formed may be attached as already described. 

The root for the reception of such a crown should 



METALLIC CROWNS. 373 

be prepared as for the reception of a molar crown. 
The details in the insertion of these crowns has varied 
somewhat in the hands of different operators, but the 
aim has been in this description to so present the prin- 
ciples that any well-qualified practitioner would have 
no difficulty in executing the work in an acceptable 
and permanent manner. 



CHAPTER XI. 



EXTRACTION OF TEETH. 



GENES AL REMARKS. 



The extraction of teeth is an important operation > 
requiring for its proper performance skill, judgment, 
and experience, as well as an accurate knowledge of 
the parts involved. Success in the operation formerly 
was very uncertain ; but now, from an increase of 
knowledge in the art of dental surgery, and from 
great improvements in the instruments employed, the 
operation is generally attended with success. The an- 
cients were not strangers to this operation, as is evi- 
denced by relics found in ancient tombs, with teeth 
absent, under such circumstances as to warrant the 
conclusion that they were removed by the surgeon. 
Extracting instruments of very ancient date have 
also been found ; and ancient writers, too, refer to the 
operation as one not much more pleasant then than 
now. The demand for this operation arises not from 
fancy, fashion, or caprice, but from dire necessity — 
a necessity, too, of great frequency. Very few indi- 
viduals in this country arrive at mature age without 
being required to submit to it ; and, indeed, the ma- 



EXTRACTION OF TEETH. 375 

jority, before middle age, lose in this manner from 
four to ten teeth, and many, all. The following are 
some of the objects for which a resort is had to this 
operation : 

1. To obtain relief from pain, caused either by dis- 
ease of the pulp, by inflammation of the periosteum, 
or by any other affection involving the teeth, that can- 
not be readily controlled without their removal. 

2. To prevent pain in future. This of course, has 
reference only to those teeth which are very much de- 
cayed, or rendered useless by any cause, and which are 
liable at any time to occasion disease in the parts about 
them. 

3. To save sound teeth from the attack and ravage 
of decay. This implies those teeth which, by their 
offensive condition, would prove injurious to healthy 
teeth. 

4. To relieve a diseased condition of the contigu- 
ous parts, such as alveolar abscess, neuralgia excited 
by dental irritation, diseased antrum — and sometimes, 
indeed, remote parts, which are in many instances af- 
fected by diseased teeth. 

5. To anticipate and obviate irregularity. There 
are some cases, in which all the teeth cannot be accom- 
modated with a proper position in the arch, and in 
which the removal of one or more of them for this 
purpose becomes a necessity, if regularity and symme- 
try are to be secured. 



376 EXTEACTION OF TEETH. 

6. To prepare the mouth for the reception of arti- 
ficial dentures ; though these are sometimes inserted, 
with the roots of the teeth remaining, which is admis- 
sible only when the roots and parts about them are 
healthy ; otherwise they should be removed. 

Before anything else is done, every case presented 
should be carefully examined, in order to ascertain 
all the circumstances and conditions that might in 
any way affect the operation. It is important to ar- 
rive at a correct conclusion in regard to the tooth or 
teeth to be ■ removed ; the number of roots, their in- 
clination, and the character of their attachment; in 
what manner, and to what extent, the surrounding 
parts will be affected by their removal ; and the prob- 
able amount of force necessary for this purpose. The 
operator will in many instances be referred to the 
wrong tooth ; for a sound and healthy one is sometimes 
painful from sympathy, and standing in contact with 
a decayed and painful tooth, makes it frequently diffi- 
cult for the patient to determine in which the pain 
exists ; and sometimes difficult for the operator, too, 
especially where the decay is on a proximate portion 
of the tooth, and not easy of approach. In all such 
cases, great care should be exercised, and a thorough 
examination made. There is often extensive decay 
on the proximate side of the tooth, that is not appar- 
ent at first view. 

•The constitution is also to be noted — its peculiarities, 



GENERAL REMARKS. 377 

tendencies, and susceptibilities ; as these will often 
modify the operation. A highly nervous temperament 
will not endure an operation that one of a different 
character will undergo with impunity. There may 
also be idiosyncrasies and conditions that will forbid 
the extraction of a tooth. One of these, and not the 
least formidable, is a hemorrhagic diathesis. 

The manner of performing the operation is an im- 
portant consideration : it should not be precipitate or 
hurried. A very good criterion is, that the eye should 
critically follow, and the mind attentively comprehend, 
every, movement of the hand and instrument. It is a 
very common method to seize the tooth, turn away or 
shut the eyes, and make the most rapid motions possi- 
ble, regardless of consequences. Accidents, such as 
breakiug the tooth, fracturing the alveolus, laceration 
of the soft parts, and rupture of the bloodvessels, are 
very liable to follow a hurried execution ; and there 
are many cases on record in which injury has resulted 
from a rapid application of force in the extraction of 
teeth. The ancients were cautious in this particular : 
it is recorded of them that they made extracting in- 
struments of lead, to prevent injury from the employ- 
ment of too great force. It is difficult, always to de- 
termine the exact amount of force that may be neces- 
sary for the removal of a tooth in any given case ; 
though by long and close observation, it may be pretty 
accurately calculated ; and it is important for the ope- 



378 EXTRACTION OF TEETH. 

rator to know this, so as to prepare for the emergency, 
and to select the instrument appropriate to the occasion. 
In order to be successful, an operator must be confident 
of his ability, and to be so, he must possess it. He 
should be familiar with the anatomical structure of the 
parts to be operated upon ; should understand the 
physiological and pathological conditions of the parts 
adjacent; and should properly appreciate their influ- 
ence on, and their connection with, the teeth. 

There is a great difference in teeth with regard to 
their facility of removal. Those most difficult to ex- 
tract possess the following peculiarities : shortness and 
thickness of crown ; in the incisors, thickness — the 
edges of the superior and the inferior meeting squarely 
on, or deviating but little from their points ; freedom 
from prominences on the crowns of the molars and 
bicuspids, their masticating surfaces being smooth ; 
regularity in arrangement, all being in correct position 
and in contact with one another ; color slightly yellow ; 
denseness and thickness of alveolus ; unyielding firm- 
ness of the soft tissue ; lack of prominences on the 
gums to indicate the size and position of the roots. 
Another class of teeth, differing in characteristics from 
those of the above, are also very difficult of extraction, 
namely : those having crowns of medium length and 
of a diameter at the neck much less than at the mas- 
ticating surface ; roots long and divergent, and in some 
cases considerably curved ; and often a very firm union 



GENERAL REMARKS. 379 

with, the alveolus, so that a portion remains adhering 
to the tooth when it is extracted, which occurs more 
frequently with the superior cuspid teeth than with 
any others ; and often the septum between the roots is 
so firmly embraced by them, especially when they con- 
verge, that it is brought away with the tooth on its 
extraction. Bony union of the teeth has been enu- 
merated as one of the occasional obstacles in extraction 
of the teeth ; but this rarely if ever occurs— the mode 
of development almost precluding the possibility of its 
existence — so that it need scarcely be reckoned. Ex- 
ostosis of the root sometimes renders extraction very 
difficult, especially when the enlargement attaches to 
the point of the root, and forms a bulb larger than the 
diameter of the root elsewhere. It is then like a ball 
in a socket, and if the walls of the alveolus are thick 
and firm, and closely embrace the root, the tooth is 
very securely retained. Exostosis of the same extent 
in the inferior as in the superior teeth will render the 
former the more difficult to remove, because of the 
greater density of the inferior maxilla ; and it has been 
maintained that this cause would produce a like dif- 
ference even in the normal condition of the organs ; 
but experience does not warrant the opinion. The 
superior molars have more numerous and more diver- 
gent roots than the inferior ; and the roots of the an- 
terior superior teeth are much larger, and consequently 
have a greater amount of attachment, than the anterior 



380 EXTRACTION OF TEETH. 

inferior ones. In a healthy condition, the periosteum 
of the root has comparatively little sensibility ; but in 
proportion as it is subjected to acute disease, is the 
sensibility increased, and thus the pain consequent on 
the removal of the tooth, augmented. 

Instruments adapted to all the different forms and 
locations of the teeth are requisite in the various ope- 
rations of extraction. It is impossible to remove all 
teeth in a proper manner with but three or four instru- 
ments, as recommended by some. 

For any kind of successful manipulation in the 
mouth, and especially that involved in the extraction 
of teeth, the patient should be placed in such a posi- 
tion as to be most comfortable, and to secure to the 
operator the greatest facility of execution. But dif- 
ferent positions, of course, will be required for the re- 
moval of different teeth. Finally, there should be as 
little show of preparation, and as little display of instru- 
ments, as possible, — thus to avoid exciting the nervous 
apprehensions of the patient ; and the operator should 
at all times exhibit a gentle and encouraging deport- 
ment, yet work promptly and surely. 



INDICATIONS FOR EXTRACTION. 

The most common and imperative indication is, 
continued and violent toothache. In all cases where 
the teeth are diseased and painful, and cannot be re- 



INDICATIONS FOE EXTKACTION. 381 

stored to health, they should be removed. There are, 
however, a few cases of diseased teeth that can not be 
relieved by the present methods of treatment, so as 
to remain in the mouth with any degree of com- 
fort and usefulness. Alveolar abscess, terminating 
on the outside of the face, or tending to it, always 
indicates the removal of the offending tooth. Chronic 
inn animation of the investing membrane formerly was 
considered an indication for extraction ; but it is 
found that many cases thus affected may by judicious 
treatment be restored to comparative health. Ulcera- 
tion of the investing membrane clearly points to ex- 
traction as the remedy. Teeth that have no antago- 
nists, and that, on this account, keep up an irritable 
condition in the contiguous parts, that cannot be con- 
trolled, should be removed; and- so, as a general rule, 
should supernumerary teeth. In order to. relieve a 
crowded condition of the teeth, it is sometimes neces- 
sary to remove one or more, even though they may be 
healthy. 

Till within the last few years, the existence of an 
alveolar abscess was considered an indication for the 
removal of the tooth from which it proceeded, but 
under the present mode of treatment, except in very 
aggravated cases, a simple abscess is not reckoned a 
sufficient cause for extraction. 

The posterior teeth may be removed for causes that 
would not warrant the removal of the anterior. AIL 



382 EXTRACTION OF TEETH. 

dead teeth and roots that produce or keep up irritation 
should be removed, especially if the tendency is per- 
sistent. 

The temporary teeth that are not cast at or near the 
time their respective permanent teeth should appear 
through the gum, ought to be removed ; but caution 
must always be exercised, lest they be removed too 
soon. Painful and uncontrollable disease may indi- 
cate their removal long before the period just men- 
tioned ; yet they should not be removed on account 
of diseased condition unless the rudiments of the per- 
manent teeth are likely to suffer by such disease. A 
crowded condition of the permanent with the tempo- 
rary teeth may indicate the removal of one or more 
of the latter. It is important to understand the true 
indications for the removal of temporary teeth ; in 
these, as in the permanent teeth, apparent indications 
are liable to be mistaken for real ones. Teeth may 
sometimes, even though undecayed, produce nervous 
affections, and in such a manner as to render their re- 
moval necessary. This indication is most frequent 
with teeth affected by exostosis. 

A high state of inflammation in the contiguous 
parts is regarded by some as a counter-indication ; 
but it can be such only in cases in which the inflam- 
mation would be increased by the operation ; and this 
would happen only where there is a decided inflamma- 



EXTRACTING INSTRUMENTS, 383 

tory diathesis, whiclv peculiarity can be readily de- 
tected by careful observation. 



Extracting Instruments 

Numerous and various instruments have been em- 
ployed for extracting teeth ; and each of these has 
passed through various modifications. Imperfection 
and want of adaptation have, till within a few years, 
characterized them all in a marked degree, as indi- 
cated by numerous changes they have undergone. 
Two general classes comprehend them all, represented 
by the key and the forceps. The former makes its 
attachment on one side of the tooth, coming in con- 
tact with but a small portion of it, and has a resting- 
point for a fulcrum on the adjacent parts, the gum 
and the alveolus. The latter embraces the tooth on 
both sides, and has no fulcrum resting on the adjacent 
parts. There are other instruments somewhat different 
from these in their application ; but the principle on 
which they operate is the same. For instance, the 
elevator has a point of embrace or contact with the 
teeth, and a fulcrum or resting-point on the adjacent 
parts, the power being applied to the handle, as to a 
lever. The screw makes its attachment inside of the 
tooth, instead of outside, like the forceps, and does 
not touch any other part. 

There should always be at hand a sufficient nuiii- 



384 EXTRACTION OF TEETH. 

ber and variety of instruments to meet ev>ery case, 
however rare its occurrence. Desirabode recommends 
the employment of but four instruments for the re- 
moval of all the teeth. The first is a forceps, and the 
other three are nothing more than so many different 
forms of the elevator. He was not familiar with the 
present improvements in extracting instruments, or he 
could not have made such a recommendation. 



The Key. 

The principle of this instrument was at a very 
early period brought into requisition for the extrac- 
tion of teeth ; it is emphatically an old instrument. 
It consists of a shaft six inches long, with a handle 
four inches, attached at right angles, while the hook 
is attached laterally at the other end of the shaft, and 
the bolster, either movable or fixed, to the side of it, 
immediately below the articulation of the hook. This 
instrument has passed through a great variety of forms 
and modifications ; having the shaft straight, curved, 
or double curved ; the fulcrum large, small, flat, round, 
long, short, fixed, movable, and anterior, posterior, or 
opposite to the point of the hook. There has also 
been a great variety of forms of the hook ; and it 
has been made with machinery attached, to control its 
grasp, the object of which is to prevent the instrument 
from slipping off the tooth, and skill in the use of 



THE KEY. 385 

which would doubtless add to the efficiency of the in- 
strument. The principle of the forceps, too, has been 
combined with the key, and probably with very de- 
cided advantage. 

The modus operandi of the key is worthy of some 
consideration. The hook is attached to the shaft di- 
rectly above the bolster, and starts off at a right angle 
with its vertical axis, but curves down to the point, 
almost or quite as low as the base of the bolster. 
When properly constructed, the hook embraces the 
tooth at the neck on one side, and the bolster rests a 
little below this on the other. When the instru- 
ment is applied to a tooth, the centre of the shaft is 
the axis of motion, ; but as force is applied to the in- 
strument, this axis is transferred from, the shaft to the 
base of the bolster, which is the centre of motion the 
moment it is fixed on the gums and alveolus, and the 
shaft describes an arc about it. Now, as a result of 
this motion and arrangement, the line of force is at 
an angle of from forty to sixty degrees with the axis 
of the tooth ; and hence it is at this angle that the 
tooth must be extracted, if at all. The axis of power 
exerted on the tooth by the instrument is in a line 
from the point of the hook to its attachment to the 
shaft ; and the line of this force has its termination 
below the neck of the tooth on one side, and just 
above the crown on the opposite side. The angle 
formed by the line of power with the axis of the 

25 



386 EXTRACTION OF TEETH. 

tooth is different in the different relative positions of 
the key to the tooth. If the instrument is applied to 
an inferior molar, with the bolster on the inside, the 
angle of the line of force with the axis of the tooth is 
about forty degrees ; but if placed on the outside of 
the jaw, as recommended by some, the angle con- 
tained by the line of power and the axis of the tooth 
is sixty degrees or more. The line of force is not 
changed by any form the hook may assume ; — it may 
be regularly or irregularly curved, or be turned at 
<a right angle, and yet the line of force is not changed. 
Indeed, this line cannot be changed except by chang- 
ing the relative position of the hook and its attach- 
ment. This application of the power constitutes one 
of the prominent objections to the use of the instru- 
ment ; the force is applied at too great an angle with 
the axis of the tooth, and hence in numerous instances 
it is broken off. The bolster of the key rests, in 
the operation, on the gum, on which it exerts great 
pressure, and which it always bruises, and frequently 
lacerates in a cruel manner ; the pressure exerted by 
the bolsters of the variously constructed keys differs 
but little ; though, perhaps, the bolster which has a 
broad base, and is attached to the shaft by a joint, 
would cause less pain to the patient by its pressure, 
and be much less liable to lacerate or cut the gum, 
than the small and permanent one. The pressure of 
the bolster on the gum and process is always greater 



THE KEY. 387 

than the power required to extract a tooth ; and this 
extreme pressure and its consequences constitute an- 
other strong objection to the use of the key. The 
power being applied at a disadvantage, much more 
is required than when economically applied. 

This instrument is so seldom employed for the ex- 
traction of teeth, that any very special directions as 
to its use will scarcely be required ; yet a few general 
suggestions may not be out of place. Whether a 
tooth should be drawn inward or outward depends 
on its position and inclination. As a general rule for 
the removal of the molars, the bolster should be 
placed on the inside of the inferior teeth and on the 
outside of the superior. For removing the lower 
teeth of the left side, the operator should stand at tbe 
right of the patient ; and for the teeth of the right 
side, in front or at the right. For the inferior teeth 
of the right side, he should stand at the right of the 
patient ; and for the left superior, in front of him. 
There have been a great many different opinions as 
to the manner of applying and using this instrument. 
One recommends that "the teeth should be always 
turned towards the tongue." Another, "that the 
fulcrum should be so placed that it would not come 
in contact with the tooth." Another directs : " Place 
the fulcrum on the margin of the gum." Another : 
" Place the fulcrum on the gum below its margin." 
Another suggests, " that the fulcrum be placed on the 



388 EXTRACTION OF TEETH. 

side of the tooth opposite the point of the hook." 
Again : "We are directed that the tooth should be 
drawn from the higher alveolus." This great diversity 
of opinion as to the manner of using the key, as well 
as the great variety of changes in its form, is evidence 
that it is, at best, a very imperfect instrument. It is 
impossible to embrace a tooth as deep with it as with 
well-constructed forceps ; and with it, the liability to 
accident in the extraction of teeth is much greater 
than with any other instrument. A strong advocate 
of this instrument says that the key always produces 
injury ; but the greatest skill exhibits the least injury. 

Foeceps. 

The forceps are the most efficient extracting instru- 
ments in use, and the improvements made in them 
during the last few years have been very great ; in- 
deed, twenty-five years ago they were not made with 
any special adaptation whatever,, and were totally un- 
fit to. be used for the extraction of teeth ; but now 
they are constructed with such various shapes and 
curves as to facilitate their approach to the teeth 
whatever their position in the mouth may be, and to 
fit all the various forms, and make a most perfect em- 
brace of the teeth. Forceps, with the present im- 
provements, take a deeper and more thorough hold on 
the teeth than any other instrument. The beaks may 



FORCEPS. 389 

be made so thin that they will penetrate between the 
roots and alveolus, and the adaptation so complete that 
the instrument will not slip or move from its position 
when placed. The form of the beaks should be such 
as to fit the crown without pressing on it, and yet per- 
fectly embrace the neck of the tooth ; and the entire 
instrument of such form and curve as to give to the 
hand, arm, and body of the operator the best position 
for ease and facility of execution. 

There are various opinions as to the position, rela- 
tive to the patient, which the operator should occupy 
while extracting teeth with the forceps. Some recom- 
mend different positions for the removal of different 
teeth; but it is preferable, on many accounts, to oc- 

Fig. 100. 



cupy as nearly as possible the same position in the re- 
moval of all ; and this is to the right and a little back 
of the patient. 

The forceps for removing the superior incisors are 
straight and have thin beaks, which are sufficiently 
broad to embrace the anterior and the posterior sur- 
faces of the teeth entire (Fig. 100) ; and they should 
be much broader for the centrals than for the laterals. 



390 EXTRACTION OF TEETH. 

The points should not be so broad, however, as to come 
in contact with the contiguous teeth in the rotary 
motion made to break up the attachment. The same 
principle in regard to the width of the forceps is to 
be observed for the lateral incisors and cuspids. The 
ordinary straight root forceps may be employed for 
the extraction of the lateral incisors ; though,, for this 
purpose, it is desirable that their beaks be somewhat 
thinner than usual. For the superior cuspid teeth, 
the ordinary bicuspid forceps are frequently used, but 
their beaks are commonly too narrow, and those of the 

Fig. 101. 




n 

central incisor forceps too thin. The cuspid forceps 
should be about as wide as those for the central in- 
cisors, with the thickness of the bicuspid forceps (Fig. 
101), and with a greater concavity, so as to fit the 
neck of the tooth. The superior bicuspid forceps 
have narrow, thick, and quite concave beaks, and the 
instrument is straight, or nearly so,, though, for the 
second bicuspids, especially in a small mouth, it should 
have some anterior curvature. (Fig. 102.) One pair 
of forceps will serve for both sides, though it is de- 
sirable to have one for the first and another for the 



FORCEPS. 



391 



second bicuspid. For the removal of the bicuspids there 
is a form of forceps with thick, smooth beaks, and of 
such a form as, by pressure, to force the tooth from 
its socket, taking advantage for this purpose of the 



Fig. 102. 




conical form of the root. The superior molar forceps, 
a pair for each side, have one of the beaks a single 
concave, to embrace the palatine root, and the other a 
double concave, with a projecting jDoint from the 



Fig. 103. 




centre of the beak, to pass into the bifurcation, and 
with the edge of the beak so formed as to embrace 
the two palatine roots. The concavity and curvature 



392 



EXTRACTION OF TEETH. 



of the beaks should be just sufficient to accommodate 
the crown of the tooth. These forceps should have a 
double curve to facilitate their approach to the teeth, 
an anterior curve just above the joint, and a down- 
ward curve just below it; sometimes, also, a lateral 
curve above the joint, throwing the instrument more 
toward the angle of the mouth. (Fig. 103.) 

For the second molars, the forceps should have a 
little more curve above the joint than for the first. 

Fig. 104. 




A third pair of forceps for these teeth, and especially 
for the roots before they are separated, have the inner 
beak similar to the one above, and the outer a curved, 
attenuated, sharp point, to pass between the buccal 
roots (Fig. 104). The forceps for the superior third 



FORCEPS. 



393 



molars have two single-concave beaks, made to em- 
brace the tooth as though it were cylindrical, or nearly 
so, at its neck. The instrument has two curves, or 
rather angles, the one forward and the other down- 
ward, so that its handle is somewhat anterior to, but 

Fig. 105. 




almost parallel with the axis of the tooth. (Fig. 105.) 
It is a principle that should be observed in all forceps, 
that the handle of the instrument when placed upon 
the tooth be as nearly parallel with the axis of the 



Fig. 106. 




latter as possible, and as nearly in a line with it as the 
location of the tooth, the size of the mouth, and other 
circumstances will admit. 
. The forceps for the inferior incisors may have either 



394 



EXTRACTION OF TEETH. 



a lateral or a transverse curve, — almost to a right an- 
gle if transverse, but if lateral, not more than half that 
inclination. (Fig. 106.) The ordinary, slightly curved 
root forceps may be used for the extraction of these 
teeth. (Fig. 107.) The beaks should be very narrow 

Fig. 107. 




and thin, for a great amount of force is not required 
for the extraction of these teeth. The beaks of the 
inferior incisor forceps should be relatively broader 



Fig. 108. 




than those of the forceps for the superior incisors. 
Rotary motion in the extraction of inferior incisors is 
not admissible unless the roots be cylindrical,, or nearly 
so. The inferior bicuspid forceps are well adapted to 



FORCEPS, 



395 



the removal of the inferior cuspids also. These forceps, 
two in number, one for each side, are of different forms. 
(Fig. 108.) The beaks are narrow, thick, and quite 
concave. The instrument for the right side has a lat- 
eral curvature, which brings the handle out at the 
angle of the mouth, and is necessary in order to obviate 
a contact with the superior teeth. The forceps for the 
left side have beaks of the same form. They are bent 

Fig. 109. 




to almost a right angle above the joint, while below it 
the handle is thrown upward ; and their inner beak is 
longer than the outer. The inferior molar forceps 
(Fig. 109) are two in number, that for the right side 
being curved outward and forward, and that for the 
left forward and upward, the beak making almost a 
right angle with the body of the instrument, and the 



396 EXTRACTION OF TEETH. 

inner beak of each being longer than the outer. The 
beak should be of sufficient breadth to embrace the 
entire side of the tooth, of double-concave form, with 
a ridge and a long point in the centre of the beak, to 
pass into the bifurcation of the roots. The inner beak 
of these forceps should be longer than the outer, for 
the teeth on which they are designed to operate have 
an inward inclination, and the outer alveolus is higher 
than the inner. 

A. pair of forceps for the left side, similar in form to 
those for the right, would be preferable to the ordinary 
left forceps, when the mouth can be opened wide ; and 
the curvature of the handle of this instrument would 
be toward the centre of the mouth, instead of outward, 
as that of the right forceps. With this form of forceps 
more power can be exerted than with the ordinary left 
inferior forceps. 

A forceps similar in general form to that for the ex- 
traction of the inferior molars of the right side has been 
devised by Dr. J. A. Watling, for the removal of the 
lower molars of the left side. 

The instrument has a little more upward and for- 
ward curve above the joint than for the right side, to 
facilitate its approach to and action upon the tooth for 
which it is designed ; it is a little longer than that for 
the right side. This instrument is much more easily 
controlled than the ordinary forceps used for extract- 
ing these teeth, and with it more force can be applied. 



FORCEPS. 



397 



It is far preferable to any forceps hitherto used for the 
extraction of the left inferior molars. It is represented 
by Fig. 110. 



Fig. 110. 




Forceps for the removal of the inferior third-molars 
have large single-concave beaks, to make a general 
embrace of the tooth, and have but one curve, which 
is between the joint and the point, and is almost a 
right angle. (Fig. 111.) One pair of forceps of this 

Fig. 111. 




kind is quite sufficient for both the right and the left 
side. The forceps denominated Physic's forceps are 
also sometimes employed for the removal of the third- 
molars. These are constructed with thick, sharp 
blades, the edges of which come squarely together, and 
the points sometimes have an enlargement on them. 
They are curved almost to a right angle, to facilitate 
their adaptation. (Fig. 112.) There are two or three 
different forms of Physic's forceps. 



398 EXTRACTION OF TEETH. 

Of the variety of root forceps now used, those for 
the removal of the anterior teeth are straight, or but 
slightly curved, with long, thin, sharp-edged beaks, 
and of a width regulated by the diameter of the roots, 
Those for the removal of the roots of the superior 
molars, when these are separated, have the same form 
of beaks as those for the front teeth, but more curved, 
to facilitate their approach to the roots. For the re- 

Fig. 112. 




moval of these roots, it is well to have several pairs 
of forceps with different degrees of curvature, using, 
in any given case, those with the least admissible 
curve, — which in a small mouth will be considerable, 
while in a large one it will be very slight. The same 
forceps that are used for the removal of the front 
inferior teeth are applicable to the removal of their 
roots. 

Of the different forms of forceps for the removal of 
the roots of inferior molars, those for the extraction 
of the roots before they are separated, and while they 
are firmly attached, have two long, slender, round, 
curved beaks, designed to pass down deep between 
and embrace the roots in the bifurcation ; their curva- 
ture should be almost a right angle, and their handles 



FORCEPS. 



399 



assume the form of the ordinary right and left inferior 
molar forceps, already described (Fig 113) ; or if but 
one is used, the handle should be straight. The for- 



Fig. 113. 




ceps for the removal of these roots after they are sep- 
arated should have the beaks of the same form as 



Fig. 114. 




those of the superior root forceps ; but the beaks 
should be curved to a right angle with the handle, 
and the handle be straight. (Fig. 114.) 



400 



EXTRACTION OF TEETH. 



Elevators. 

There are in use variously-formed instruments con- 
structed on the principle of the elevator. They are 
made with such points as to take the most thorough 
hold on the teeth or roots on which they are to be 
used, and with such curvature of shaft as to enable 
them to pass most readily to the desired position. 

Fig. 115. 




Some are so formed at the points as to embrace the 
root at the border of the alveolus, using the latter as 



Fig. 116. 




a fulcrum (Fig. 115) ;, others, to pass between the al- 
veolus and the root (Fig. 116) ; others to cut through 
the alveolus, and thus approach the root. All the or- 
dinary elevators make a fulcrum of the alveolus, or of 
an adjoining tooth ; but some operators, in using this 
instrument, contrive to make a fulcrum of the thumb 
or one of the fingers, which is the preferable way. 



HOOKS — SCREW. 



401 



Hooks. 

These are formed so that the point will embrace 
the root and remove it, without resting on the sur- 
rounding parts. The root is removed simply by pres- 

Fig. 117. 




sure, applied in the proper direction. Of the various 
forms of this instrument, there are the forward hook, 
the backward (Fig. 117), and the compound (Fig. 



Fig. 118. 




118), which last includes the former two. These are 
valuable instruments, but require care, in order to 
avoid injuring the surrounding parts. 

Sceew. 



This is a cone-shaped instrument, with a very defi- 
nite, sharp screw-thread ; the manner of using it in 
the operation of extraction is, to screw it into the root. 
It will be required of various sizes, to correspond with 

26 



402 



EXTRACTION OF TEETH. 



those of the different roots to be extracted. It is 
commonly attached to the handle by a permanent 
shaft (Fig. 119) ; but sometimes it is made with a 



Fig. 119.. 




square shaft fitted into a socket handle (Fig. 120), 
by which arrangement the handle is used only to in- 
troduce the screw ; and this only serves as a support 
to a frail root, the forceps being then brought to bear 



Fig. 120. 




in connection with it for the removal of the root. A 
screw-tap of the same form as the screw should accom- 
pany it. 

When the screw is combined with the forceps for 
the purpose of supporting the root, and preventing it 
from crushing while it is removed with the forceps,, 
the latter is of the same form as that of the ordinary 
straight root forceps, with the shaft of the screw at- 
tached in the joint. In some, the screw is attached 
with a spring and ratchet, so that it can be drawn out, 
seized between the beaks, and introduced into the root; 
and then, these are slipped on the root, which they 



GUM-LANCET. 403 

embrace and remove. In others, the screw is fixed, 
but the movable screw is to be preferred. (Fig. 121.) 
An arm attached by a joint, and bearing a pad to rest 

Fig. 121. 



as a fulcrum on the other teeth, is sometimes attached 
to the shaft of the screw., but this is objectionable, be- 
cause of its liability to impede the action of the in- 
strument, and also to injure the adjoining teeth. 

Gum-lancet. 

Of the various forms of the gum-lancet, the most 
common is that with the round point, and with the 
blade from two to four lines wide, and from half an 
inch to an inch long, attached to a shaft and handle, 
the whole being about six inches in length. The in- 

Fig. 122 




strument should have a keen edge on the sides, two or 
three lines from the extreme point. It is sometimes 
made with the edge square, but the round edge is the 
better form. The edge is parallel with the handle in 
the ordinary lancet. (Fig. 122.) This form is used 



404 EXTRACTION OF TEETH. 

for separating trie gum from the buccal and palatal 
surfaces of the tooth. A lancet with the edge trans- 
verse to the shaft is required for separating the gum 
from the proximate portions of the teeth. The blade 
of this should be of the same general form as that 
already described, except that it should be quite nar- 
row, in no case more than two lines wide. (Fig. 123.) 

Fig. 123. 




Gum-lancets are made with the blade set in a socket 
on the end of the shaft, so that it can be rotated and 
set to any angle to meet every case. 

The Method of Lancing the Gums. 

In all cases the gum should be separated from the 
tooth as far as the embrace of the forceps is to extend ; 
the lancet should pass close to the tooth, so as to make 
the separation clean about its neck; in order to do 
which the lancet must be kept in good condition ; it 
should also be passed freely between the teeth. A 
complete separation of the gum is essential to a good 
hold of the forceps on the tooth. Some operators, 
however, do not use the lancet for this purpose, but 
tear the gum away by forcing the forceps to its posi- 



METHOD OF LANCING THE GUMS. 405 

tion on the tooth. This method is objectionable on 
several accounts : it causes the patient much more pain 
than with a sharp lancet; the forceps cannot thus be 
adjusted to the tooth with so much facility; there is 
far more danger of lacerating the soft parts, and be- 
cause of an imperfect adaptation of the forceps to the 
tooth, more danger of fracturing it ; and the opera- 
tion is always more difficult of accomplishment. In 
those cases in which the gum is firm and dense, and 
would obstruct the free passage of the forceps io the 
proper position on the tooth, it is sometimes necessary 
to make a vertical incision of the gum, even after it 
has been separated, directly opposite the root. But it 
is in many instances better to cut away a portion of 
the free margin of the gum in the extraction of roots 
that are partially covered by it; and there is no objec- 
tion to this method in any case where it may at all fa- 
cilitate the operation; for this portion of the gum, if 
let remain, is always absorbed or sloughed away after 
the extraction of teeth. It is also sometimes necessary 
to dissect the gum somewhat from the alveolus, in 
those cases in which a deep hold on the tooth or root 
is required, and in which the alveolus is either cut 
away or embraced by the forceps. The character and 
condition of the tooth will somewhat modify the ex- 
tent to which the gum-lancet should be used. 



406 EXTRACTION OF TEETH. 

Extraction of the Teeth. 

In the following remarks it is the design to consider 
only those principles obviously involved in the ex- 
traction of the teeth with forceps, and in the extraction 
of roots with forcejDS, elevators, and screws. 

Superior Incisors. — After an examination, the gum 
should, iu all cases, be perfectly separated from the 
neck of the tooth up to the border of the alveolus; 
this is quite sufficient if the tooth is not too much de- 
cayed. With the forceps already described (see Fig. 
100), grasp the tooth firmly at' the border of the al- 
veolus; introduce the instrument slowly, adjusting it 
carefully as it passes up to the proper position; then, 
by a gradual movement, rotate the tooth in the socket, 
thus breaking up the attachment. All the cylindrical, 
single-root teeth may be luxated by a rotary motion. 
There are occasional circumstances, however, that ren- 
der this somewhat difficult ; as, for instance, any con- 
siderable curvature of the root, or, sometimes, the at- 
tachment to the outer plate of the alveolus is so firm 
that it cannot be broken up by rotary motion. Neither 
of these difficulties is usual with the lateral incisors; 
but with the centrals, one or other of them, is not un- 
frequent. When either of them does occur, the at- 
tachment must be broken up by an inward and out- 
ward movement, which, on account of the pressure 
made on the parts, is attended with much more pain, 



EXTEACTIO^ T OF TEETH. 407 

.and far greater danger to the contiguous parts than the 
loosening by rotary motion. 

The roots of the incisors are not difficult to remove, 
unless, being very much decayed, they will not sustain 
the embrace of the forceps below the border of the 
alveolus; and when they are thus decayed, one of the 
following methods may be adopted: The gum may be 
dissected from the alveolus, and the latter cut away 
with the thick cutting instrument, so as to expose the 
root sufficiently for extraction with the root forceps ; 
or, after the gum is dissected up, the alveolus and the 
root may be together embraced, and the former bro- 
ken -and removed with the latter. This is a rough 
and severe operation, though it is often adopted. Or, 
an elevator of the proper form may be introduced 
between the root and the alveolus, and the root thus 
dislodged. 

The screw, either simple or compound, is a valuable 
instrument for the removal of these roots. But the 
gum should be separated even when the extraction 
is to be accomplished with this. The canal in the 
root should first be enlarged with a taper drill of the 
same shape as the screw, till all the softened dentine 
is removed. Then the screw, selected of proper size, 
having a very sharp thread, is introduced, till it takes 
a strong hold in the solid dentine, especially if it is 
the simple screw. In some instances, while it is being 
introduced, the root will be loosened. In using the 



408 EXTRACTION OF TEETH. 

screw in connection with the forceps, it is not necessary 
to introduce it with the same firmness as when the 
screw alone is employed. In the use of the screw- 
forceps, the screw is embraced in the beaks and intro- 
duced; then the forceps are passed up on the root, or 
between it and the alveolus, if need be, the screw serv- 
ing to sustain the root under the pressure of the for- 
ceps. The attachment of the root is broken by a 
rotary, or an inward and outward movement, as the 
case may require. 

Superior Cuspids. — For the removal of these teeth, 
the central incisor or the bicuspid forceps may be 
used, though usually the beaks of the former are too 
thin, and those of the latter too narrow. The forceps 
appropriate for the removal of these teeth have broad, 
deep, concave beaks, so as to embrace the tooth as 
completely as possible, and they are thick, so as to 
possess sufficient strength. The gum being separated, 
and the forceps adjusted on the tooth, the attachment 
is broken up either by an inward and outward, or by 
a rotary movement ; the former will be far more fre- 
quently brought into requisition, since these teeth 
are generally so firmly attached that they cannot be 
loosened by the latter; but the skilful and experienced 
operator will often combine the two, with the happiest 
effect. These teeth have larger roots than any others 
in the mouth, and the alveolar process, especially the 
outer plate, closely invests them, and thus they are 



EXTRACTION OF TEETH. .409 

very firmly fixed in the sockets, and are also more fre- 
quently found curved than the roots of the incisors.. 
Often, in the extraction of the cuspids, a portion ot 
the outer wall of the alveolus is broken off,, and comes 
away with the tooth. But this accident is not attended 
with any serious results; indeed, in the preparation of 
the mouth for artificial teeth, it is desirable that it be 
broken away somewhat. 

The movement in the extraction of a tooth should 
always be very deliberate — never sudden and violent. 
A very good criterion in regard to the rapidity of 
movement is, that the eye should follow and distinctly 
recognize every motion of the forceps, the tooth, and 
the contiguous parts. 

The removal of the roots of these teeth is far more 
difficult than that of the incisors. Frequently the gum 
has to be separated up two or three lines on the alve- 
olus, and the latter broken in with the forceps, before 
the root is removed. The compound screw is often 
very valuable in the removal of these roots, — the sim- 
ple screw not commonly being of much avail, since 
the force necessary to extract the root is generally so 
great that the screw alone will not take a sufficiently 
firm hold to accomplish it. The elevator is not a very 
efficient instrument in the removal of these roots. 

Superior Bicuspids. — For the removal of the bicus- 
pid teeth of both sides, one pair of forceps is quite 
sufficient. (See Fig. 102.) These forceps are without 



410. EXTRACTION OF TEETH. 

any curve ; though in a small mouth, for the second 
bicuspids, a slight anterior curve would be desirable, 
since it would admit the instrument to a better posi- 
tion on the tooth. These forceps properly adjusted 
on the tooth, according to the directions already given, 
the attachment is broken up by an inward and out- 
ward movement, carried just to the extent necessary 
to accomplish the object; and then traction is applied 
to remove the tooth from the socket. This applica- 
tion of the force is specially adapted to the first bicus- 
pids. Rotary motion should be very seldom applied 
to these teeth, because their points generally terminate 
in a bifurcation, and it is impracticable thus to detach 
them without breaking off at least one of the roots; 
and where they do not bifurcate, they are so much 
compressed as generally to forbid such a force. Occa- 
sionally, however, there is but one root, and this is 
nearly cylindrical, as will be indicated by the cylin- 
drical form of the crown and neck of the tooth ; and 
in such cases the rotary may be combined with the in- 
ward and outward motion. The root of the second 
bicuspid commonly has no bifurcation, and is usually 
somewhat compressed ; and, in general, the rotary mo- 
tion may be combined with the inward and outward 
in its extraction. There is occasionally, however, some 
curvature to the roots of these teeth ; but very seldom 
is it sufficient to cause any difficulty in their removal. 
The skilful and experienced operator will in most cases 



EXTRACTION OF TEETH. 411 

determine very accurately the size, shape, and position 
of the roots by the jDeculiarities of the crown ; and the 
attention of the young practitioner should be directed 
very closely to this point, till he is able to arrive at 
accurate conclusions. For the removal of these teeth, 
there are forceps with thick, peculiarly-formed beaks, 
constructed to take advantage of the conical shape of 
the roots. The instrument is placed on the tooth at 
the border of the alveolus, or, if need be, a little be- 
yond it ; and then, the process having been first cut 
away, firm compression is made on the handle of the 
instrument, and thus great pressure on two opposite 
sides of the root, — which are relatively as two inclined 
planes, — by which the tooth is forced directly from its 
socket, without either the oscillating or the rotary mo- 
tion. This instrument is rarely ever applicable to the 
removal of any other teeth than the second bicuspids, 
and occasionally the central incisors, and then only 
when the roots are very tapering. The roots of the 
bicuspids, especially the second, are usually not difficult 
to remove. Sometimes, however, the first bicuspids 
have two well-formed roots, somewhat divergent, that 
are difficult to remove, especially if the decay has eaten 
away till there is little of the tooth left for the instru- 
ment to take hold upon. But, frequently, if one of 
the contiguous teeth is absent, a lateral seizure will 
remove the root at once. 

Root forceps with narrow, thin beaks, which may 



412 EXTRACTION OF TEETH. 

be readily forced between the root and the alveolus, 
are very valuable for the extraction of all small roots. 

The screw, whether simple or compound, is not ap- 
plicable to the extraction of the roots of the bicuspids. 

A bicusj)id will sometimes stand somewhat out of 
the true circle, and the contiguous teeth approximate 
so that it will not pass between them. In such a case, 
the principal part of the movement for its detachment 
should be in the direction of its inclination. The cus- 
pid teeth are sometimes found in the same condition, 
and a similar application of force for their removal is 
to be made ; indeed, this method is appropriate to all 
cases where the teeth stand out of a proper position, 
and the contiguous teeth impinge on the space. 

Superior Molars.— The first and the second superior 
molars have each three roots, one palatal, and two 
buccal ; the palatal being the largest and longest, and 
the anterior buccal larger than the posterior. The 
palatal root diverges very considerably from the axis 
of the tooth, while the buccal are often parallel with 
it and with each other ; but they sometimes diverge 
in both directions. Occasionally the divergence of 
some or all of these roots is so great, that they can- 
not pass out of the socket without either fracturing the 
alveolus or breaking off one or more of the roots. On 
the contrary, there is sometimes such a convergence 
of the buccal roots, that the intervening portion of 
bone is necessarily brought away with the tooth. In- 



EXTRACTION OF TEETH. 113 

deed, the three roots are sometimes found all in con- 
tact, forming an irregular conical root ; but this is a 
condition of unnatural development. 

The appropriate forceps being firmly fixed on the 
tooth, an outward and inward movement is applied, 
and traction at the same time. In the examination 
of these teeth, to ascertain the force necessary for 
their removal, two particulars have to be considered : 
the firmness of the attachment, and the jjosition and 
inclination of the roots. When these teeth, as they 
occasionally do, stand somewhat outside of the cor- 
rect position, great care must be exercised in their 
removal, especially if the contiguous teeth impinge. 
In small mouths, the contiguous impinging tooth is 
liable to be injured by the pressure in extraction ; but 
this injury may be avoided by directing the pressure 
backward. Commonly, the first effort made to break 
up the attachment should be outward, except where 
the tooth stands inside the circle, or where it is de- 
cayed very much on its inner side, while its outer 
remains firm. In those cases in which the roots di- 
verge so much that they will not pass out of the socket 
without tearing awav some of the wall of the alveo- 
lus, it would be impossible to break up the attach- 
ment by an inward movement, for the palatal root 
braces the tooth, and the inner process is very strong 
and unyielding. Where a molar has decayed on its 
proximate sides, and the contiguous teeth encroach on 



414 EXTRACTION OF TEETH. 

it, so that it cannot pass out directly between them, it 
must either be cut away with the chisel, file or disk, 
till it is small enough to pass out, or be drawn from 
between them. 

The decay on the buccal or palatal sides often ex- 
tends below the gum, and even below the border of 
the alveolus ■; or there maybe extensive softening of 
the dentine of the crown ; in either case, the gum and 
process must be cut away sufficiently to admit a firm 
hold on the root where it is strong enough to sustain 
the embrace of the forceps. 

Extraction of Roots. — The extraction of the roots 
of the superior molars is not attended with much 
difficulty when they are separated by decay, or are 
easily broken apart ; the method then is the same as 
for single roots. They should be deeply embraced 
with the curved, sharp-pointed root forceps (see Fig. 
107), and rotated to break up the attachment, trac- 
tion being applied at the same time. It is very rarely 
necessary to resort either to the elevator or to the 
screw for the removal of these roots. The greatest 
difficulty is experienced when the bifurcation is deep 
and the roots all adhere firmly together. In such case, 
the same force is required for their removal as before 
the crown was decayed off. The root forceps, shown 
in Fig. 104, can be very effectively used in the extrac- 
tion of these roots. The round sharp beak is passed 
between the buccal roots, the other beak embracing 



EXTRACTION OF TEETH. 415 

the palatal ; and with this hold, by an inward and 
outward movement, the root is removed. These forceps 
are not applicable where there is but one large conical 
root. For the removal of roots of this form, the third 
molar forceps, or those with similar beaks, are required. 
When it is necessary to dissect off the gum, and cut 
away the process, in order to obtain a firm hold of 
the root, this should be done in preference to crushing 
in the jDrocess with forceps — except, indeed, it may 
be the case of a very irritable patient, who will not 
tolerate a protracted operation, in which case it is 
better to complete the operation at a single effort. 

Third Molars. — There is not usually much difficulty 
attending the extraction of these teeth. The appro- 
priate forceps for this purpose (see Figs. 105 and 111) 
have two large single-cOncave beaks, so formed as to 
embrace the neck of the tooth, without any reference 
to the bifurcation or the number and position of the 
roots. Ordinarily, the attachment of these teeth is 
broken up by the inward and outward movement ; but 
where a single, round, conical root is clearly indicated, 
the rotary movement would be preferable, or the ro- 
tary in conjunction with the inward and outward. 
These teeth sometimes stand out of the true position, 
more frequently inclining outward, as already sug- 
gested in another place ; and the direction of the force 
for their extraction will correspond with this inclina- 
tion. 



416 EXTRACTION OF TEETH. 

Sometimes these teeth are very difficult to extract; 
and this difficulty is dependent on the following cir- 
cumstances : first, an anterior inclination of the tooth, 
so that it stands at a considerable angle with the 
adjoining tooth, and in contact with its posterior 
proximate surface, the posterior border of the process 
being thick and firm, and extending down full on 
the crown of the tooth ; and second, the existence of 
several roots, with great divergence, irregularity, and 
curvature. The removal of a tooth in the first of 
these conditions is often a very protracted operation, 
fraught with much pain to the patient and consider- 
able labor to the operator. Such preparation must 
be made as will permit a free egress of the tooth from 
;the socket, before an effort is made for its extraction. 
This is effected either by cutting away the portion of 
process behind the tooth, so that it may be forced 
^backward sufficiently to let it pass out of the socket, 
or by cutting away enough from the anterior portion 
of the tooth ; or, if the posterior proximate sur- 
face of the second molar is decayed, it may be quite as 
well, and more convenient, to cut this down so as to 
permit the ready removal of the tooth. 

Physic's forceps can be used very effectively for the 
extraction of these teeth when they occupy such a 
position, provided the root is straight, or has a poste- 
rior curvature ; but if there is an anterior curvature, 
the tooth is most difficult to extract, and Physic's for- 



EXTRACTION OF TEETH. 417 

ceps would be wholly inefficient, except to break off 
the tooth. In such case, the posterior portion of the 
process should be cut away as much as possible. 
Physic's forceps are frequently employed for the re- 
moval of these teeth when they occupy a correct posi- 
tion ; but their use is somewhat objectionable, especially 
in the following respects. The instrument acts first 
on the principle of a wedge, being forced between the 
teeth ; and then on that of a lever, the second molar 
being the fulcrum ; and hence, when it is employed, 
the second molar must always be present, and is liable 
to injury from the pressure, which may do violence to 
the periosteum, or fracture and scale off portions of the 
enamel. But if the first molar is absent, there is almost 
as much liability, with the Physic's forceps, of loosen- 
ing the second as of extracting the third. Indeed, it is 
always objectionable to use a sound tooth, under any 
circumstances, as a fulcrum for an extracting instru- 
ment. 

A third molar the roots of which are irregular in 
number, inclination, and curvature, should be grasped 
firmly, and an oscillating force applied sufficient to re- 
move it from its socket. There is nothing pertaining 
to the removal of the roots of these teeth that involves 
any different principle or application of instruments 
from that given for the removal of the teeth themselves. 
The anterior inclination, which so often renders the 
whole tooth difficult of extraction, very seldom affects 

27 



418 EXTRACTION OF TEETH. 

the removal of the roots. These are, in general, easily 
extracted with the common curved root-forceps. 

Inferior Incisors. — In the extraction of these teeth, 
either of the forceps described for the purpose may be 
employed. The beaks should be quite narrow and 
thin (see Fig. 106). The instrument well fixed on the 
tooth, the attachment is broken up by an inward and 
outward movement, the rotary being seldom applicable, 
since, in general, the roots are flattened, and in many 
cases quite thin, so as to be incapable of turning in the 
socket. Care must be exercised in the oscillating 
movement, and especially where the tooth to be ex- 
tracted stands out of the proper position, and the con- 
tiguous teeth incline together ; though this is of little 
consequence where the teeth are all to be removed. 
When the crowns of these teeth are short and thick, 
the roots are shorter, thicker, more conical, and more 
nearly cylindrical ; and in the extraction of such the 
rotary may be combined with the oscillating move- 
ment. 

There is seldom any superadded difficulty in the re- 
moval of the roots of these teeth, the same instruments 
and movements being applicable as for the removal of 
the teeth themselves. The only difference in any re- 
spect is, that where the teeth are decayed off far down, 
the forceps should be forced down on the process, in 
order to obtain a firm hold on the root. Neither the 



EXTRACTION OF TEETH. 419 

elevator nor trie screw is ever required for the removal 
of these roots. 

Inferior Cuspids. — These teeth may be removed 
with the inferior bicuspid forceps of the right side, 
though an instrument of the same general form, but 
of less curvature, would be preferable, since with such 
the required movement for breaking up the attach- 
ment could be more easily given. They commonly 
have long, round, conical roots, not so large as those 
of the superior cuspids, nor so difficult to extract, sel- 
dom having any curvature, and thus being susceptible 
of detachment by the rotary motion. They often 
stand so much anterior to the true circle, that an at- 
tempt to thrust them inward would be liable to break 
•or loosen the lateral incisors. Their situation, as in- 
deed that of all teeth, should be fully comprehended 
before any attempt is made to remove them. 

The crowns of these teeth decay off, and leave the 
roots standing, far more frequently than do those of 
the superior cuspids. But there is no difficulty in the 
removal of their roots, and the only indication is, when 
they are deeply decayed, to pass the forceps far down 
on them, either first cutting away the process or em- 
bracing it, as the circumstances may warrant, the 
former method being preferable. After the root is 
extracted, the fractured pieces of process, if any, should 
be removed. 

A long, tapering screw may sometimes be ad van- 



420 EXTRACTION OF TEETH. 

tageously used for the extraction of these roots, when 
they are decayed so deeply that an extensive breaking 
away of the process would be incident to their removal 
with the forceps. The elevator, however, is rarely ever 
called into requisition here. 

Inferior Bicuspids. — These teeth, two in number,, 
on each side, have but one root each, and that gener- 
ally round, or nearly so, and not so long as that of the 
cuspids, and have less diameter at the neck. They re- 
quire, in extraction, forceps for each side, as already 
described (see Fig. 108). They may be removed either' 
by the rotary or by the inward and outward move- 
ment, or both combined. With the handle of the for- 
ceps thrown very far out of a line with the axis of the 
tooth, it is always more difficult to be rotated accu- 
rately in its socket ; a straight instrument is best for 
the rotary motion. In the removal of these teeth 
from the right side, when the mouth is small, care 
should be taken that too much pressure is not made 
against the anterior tooth. This accident is more 
liable to happen in the removal of the second bicus- 
pid than in that of the first, and especially if the 
mouth cannot be opened wide. As the tooth comes 
out the forceps are liable,- without some attention, to 
strike the superior teeth, and in this way fracture 
them or scale off their enamel. In many cases, for- 
ceps with a forward and outward curvature com- 
bined would be very desirable for facility of ap- 



EXTK ACTION OF TEETH. 421 

proaching the tooth; but with such a complication 
of curves the operator loses control of the instru- 
ment. 

In the removal of the bicuspids of the left side, 
there is little or no liability to undue pressure against 
the anterior teeth ; and in their extraction the move- 
ment should be mainly inward and outward, since 
the great curvature of the forceps renders a rotary 
motion very difficult and uncertain. There is also 
danger of striking the upper teeth, especially if the 
tooth to be extracted comes out with less effort than 
the operator anticipated — an accident that sometimes 
befalls the most skilful and discriminating. The 
first and the second inferior bicuspids are removed 
with about equal facility. 

Occasionally, though seldom, these teeth have two 
distinct, well-defined roots — a condition that cannot be 
determined by the form of the crown, or by any other 
visible indication; and one tooth alone will sometimes 
be found with this peculiarity. The removal of the 
roots of these teeth is not attended with much diffi- 
culty, the main consideration being to obtain a deep, 
strong hold on them, and then apply a firm steady 
movement. 

Inferior Molars. — These teeth commonly have two 
roots, a posterior and an anterior, the latter being the 
largest, and frequently the longest. The roots have 
different inclinations to the axis of the tooth, being 



422 EXTRACTION OF TEETH. 

in some cases divergent from, and in others parallel 
with it, and in others convergent, or curved together 
so that their points almost meet. The forms of the 
crowns will give some indication of the inclinations 
of the roots. If the former are short,, the latter are 
so, and vice versa, if the diameter of the crown is about 
the same at the masticatory surface and the neck, the 
roots do not diverge; if the crown is long and of 
uniform diameter, the roots will be either parallel 
or convergent^ and, if the angles on the crown are 
not sharp and well-defined, the roots most probably 
curve together at the points. If, however,, the an- 
gles formed by the masticatory and lateral surfaces of 
the teeth are sharp and well-defined, the roots gener- 
ally diverge'. 

Forceps adapted to each side are required for the 
removal of these teeth. These forceps have a promi- 
nence, or point, in the centre of the beaks, to pass 
into the bifurcation; and in separating the gum it is 
important to dissect it away, and, if need be, even cut 
away the margin of the process, so that the bifurca- 
tion may be well exposed, to admit the forceps to a 
proper position on the tooth without obstruction. The 
tooth being firmly grasped in the proper manner by 
the forceps, is moved gradually, but steadily, inward 
and outward, to break up the attachment, and then 
drawn from its socket. In the removal of these teeth 
from the right side, with the ordinary forceps, there 



EXTRACTION OF TEETH. 423 

is great danger of undue pressure on the anterior con- 
tiguous teeth; this is to be avoided by directing the 
pressure backward in the 023eration. And there is 
also danger of injuring the upper teeth with the for- 
ceps; this may be obviated by wrapping the point of 
the instrument with a small napkin. 

In the removal of the inferior molars of the left 
side, the application of force is the same — an inward 
and outward movement-*-but the handles of the for- 
ceps occupy different relative positions to the teeth to 
be extracted — passing directly out at the front of the 
mouth instead of at one side. In consequence of this 
arrangement, the operator cannot exert the same force 
on them as, with the proper forceps, on those of the 
right side. Very little traction can be employed in 
connection with the oscillating movement, but the 
attachment must be almost wholly broken up before 
beginning to lift the tooth from the socket. But, in 
extracting the teeth on the right side, with the proper 
forceps, traction is always combined with the inward 
and outward movement. 

In the extraction of the roots of these teeth, little 
difficulty is experienced after the decay has proceeded 
so far as to effect their separation. They are then 
embraced with the appropriate forceps, and removed 
as single roots are elsewhere. The forceps have nar- 
row, thin, sharp beaks, turn to almost a right angle. 
With them the root is embraced and moved inward 



424 EXTRACTION OF TEETH. 

and outward till loosened, and then removed. When 
the mouth is large, and can be opened wide, the slightly 
curved root forceps are convenient, and the rotary 
movement may be employed with them, if the roots are 
not very much curved, flattened or firmly set. The 
removal of these roots is more difficult when the bi- 
furcation is low down, and the roots remain firmly 
attached together, and especially when they diverge. 
If the bifurcation is not too low, and the attachment 
not too firm, the roots may be separated with the sep- 
arating forceps (Fig. 124), and then removed singly 

Fig. 124. 




as in other cases. This is the preferable method when 
there is much divergence ; but if the roots cannot be 
separated, they may be extracted with the forceps 
shown in Fig. 112. The round, curved, sharp beaks 
are passed down between the roots, and the whole is 
removed at once ; the attachment being broken up on 
the principle already described. 

These teeth sometimes have but one large, round, 
conical root ; and there is seldom, if ever, enough 
curvature of the roots to render extraction difficult. 
The ordinary inferior-molar forceps are not well 
adapted for the purpose, for the central points of their 



EXTRACTION OF TEETH. 425 

beaks will prevent a perfect adaptation. The broad, 
single-concave beaked forceps are best adapted, the 
curves and general forms of which, except the beaks, 
are the same as those represented in Fig. 111. The 
removal of teeth having roots of this kind is easily 
accomplished. Rotary movement would be applicable 
here if the exact form of the root could be ascertained 
before extraction ; but it is in general the safest course 
to employ the inward and outward movement. 

Inferior Third Molars. — These teeth require for 
their removal the broad, single-concaved beaked for- 
ceps, the beaks curved at nearly a right angle with the 
handle, and the handle straight. This instrument fixed 
deeply and firmly on the tooth, the attachment is to be 
broken up by the inward and outward movement. 
These, more frequently than the superior third molars, 
stand out of the proper position ; their variations and 
the manner of obviating the attendant difficulties, 
however, being about the same — at least, so far as 
deviation is concerned. Physic's forceps may be used 
here with greater facility than on the upper teeth. 

These teeth frequently exhibit but a very small 
portion of the crown through the gum. Being erupted 
with an anterior inclination, the tooth comes in contact 
with the posterior portion of the second molar, and is 
thus checked in its external development. Thus the 
crown is left partially covered with the gum, which 
frequently inflames, and even suppurates, remaining 



426 EXTRACTION OF TEETH. 

in that condition for a considerable time, to the great 
annoyance of the patient. Such teeth are difficult to 
remove ; first, because of their inclination and contact 
with the second molar ; and secondly, because the 
crown is more than half below the borders of the thick, 
firm, alveolus, rendering it impossible to obtain a firm 
hold on the tooth without cutting away a portion of 
the alveolus. In such cases, it is generally best to make 
a free excision of the alveolus all round the tooth, 
sufficient to permit its easy removal. 

Extraction Preparatory to the Insertion of 
Artificial Dentures. 

Whenever there is a nnmber of teeth to be removed, 
the method and the duration of the operation will de- 
pend on the following circumstances : 

First. The number to be removed., 

Second. The firmness of their attachment. 

Third. The patient's power of endurance. 

Fourth. The manner in which the immediate parts 
are affected. 

Where the number to be removed is considerable, 
and the attachment feeble, or not very firm, and the 
patient's power of endurance good, the extraction 
may be as rapid as is consistent with efficiency. In 
many such cases, from three to six teeth may be re- 
moved, without any relaxation by the operator of his 



FOR INSERTION OF ARTIFICIAL DENTURES. 427 

hold on the parts with the left hand. This is gener- 
ally practicable with the front teeth of the lower, and 
frequently with those of the upper jaw ; but it is not 
pro]3er to remove more than three or four of the molar 
teeth without respite, even when they are quite loose,, 
or have but a feeble attachment in the socket. The 
gum should, of course, be well separated previously to 
the operation. Only so many teeth should be removed 
at one sitting as the nervous system will allow without 
too great a shock. In many instances, however, it is 
practicable, so far as this is concerned, to remove at 
once all the teeth in the mouth. In the extraction of a 
large number, those most easily removed should be first 
taken, so as by degrees to bring the patient to the more 
severe operations. If there is a manifest hemorrhagic 
diathesis — a disposition to bleed freely from the capil- 
laries, as well as from the larger vessels — but two or 
three teeth should be removed at a sitting, lest uncon- 
trollable haemorrhage ensue. 

After all the teeth are removed from one or both of 
the jaws, the gums and alveolus should undergo a 
trimming process : all detached, flabby, or prominent 
portions of the gums should be dissected off; the whole 
ridge made uniform ; all loose portions of the alveolus 
removed ; all the prominent points and sharp edges 
cut clown ; and the whole border of the process ren- 
dered as smooth and even as possible. By this means, 
the healing of the parts is facilitated, and they assume 



428 EXTRACTION OF TEETH. 

the desired condition and form in mncli less time, and 
with far less soreness and inconvenience. 

Conditions to be Observed in Extraction. 

Such conditions are often found to exist in the sys- 
tem as indicate the necessity of great care in the ope- 
ration, or of prior treatment, or forbid the extraction 
of the teeth altogether. Of these conditions, the follow- 
ing are some of the more obvious : 

Extreme debility. 

Great nervous irritability. 

Excessive local inflammation, especially where it 
tends to other parts. 

Much irritability of the parts intimately connected 
with the teeth. 

Pregnancy and all uterine irritations. 

A tendency to epilepsy. 

In many cases, where there is great debility, so pain- 
ful an operation as the extraction of a tooth will cause 
extreme and sometimes alarming prostration. This, 
however, may be anticipated by prior invigorating 
treatment, continued till strength and tone are obtained 
sufficient to endure the operation. This treatment 
may occupy considerable time, while an urgent case 
may arise, in which the removal of the offending tooth 
is immediately demanded, in which case it is proper to 
administer stimulants — brandy or wine, or such as the 



CONDITIONS TO BE OBSERVED IN EXTRACTION. 429 

case may seem to require. By such means trie system 
may be so invigorated as to withstand the shock of the. 
operation with comparative fortitude. 

There is in some cases a highly irritable condition of 
the nervous system, that almost absolutely forbids the 
extraction of teeth, convulsions being sometimes pro- 
duced in such cases by a simple operation. This re- 
mark does not of course apply to facial neuralgia, that 
may be either partially or wholly produced and kept 
up by diseased teeth ; neither general nor local neu- 
ralgia would be aggravated by an operation of this 
kind. Accompanying general nervous irritability, 
there is usually excessive dread of an operation, such 
as to occasion rapid prostration — even greater and more 
rapid than that caused by the operation itself. In such 
cases, if the extraction is effected immediately, it will 
give relief; but where the excitement has been very 
high, and the tension for some time great, the depres- 
sion after the operation will be correspondingly great, 
and considerable time be required for complete recov- 
ery ; indeed, the shock is sometimes so severe as to 
occasion confinement for several days. Treatment for 
quieting the nervous system, consisting in agents of a 
sedative character, may be employed previously to the 
operation. Stimulants, as a general rule, should be 
avoided. 

Where there is a high state of inflammation in the 
immediate parts, especially if there is a general inilain- 



430 EXTRACTION OF TEETH. 

niatory diathesis, the propriety of extracting the teeth 
5s questionable. Under such circumstances, there is 
probably less danger in the extraction of the inferior 
teeth than of the superior. Where the inflammation 
has a disposition to extend, it is liable to go to the 
head from the superior maxilla, and to the fauces and 
throat from the inferior. In cases, then, where there 
is excessive inflammation in the immediate parts, ac- 
companied by a general inflammatory condition, both 
local and general antiphlogistic treatment should be 
adopted 

Extreme irritability, or a diseased condition of parts 
having an intimate connection with the teeth, as, the 
immediate surrounding tissues, the salivary glands, 
and the throat, is a circumstance admonishing to great 
caution in the extraction of teeth, especially when such 
condition does not depend on the teeth for its exciting 
cause or modifying influence. It is, however, very 
generally the case, when any of the parts having an 
intimate relation with the teeth become in any way 
affected, that diseased teeth will exercise an inju- 
rious influence on them. If the necessity for the re- 
moval of the offending tooth is not too urgent, the parts 
that may be diseased about it should be brought to as 
good a condition as possible. 

Pregnancy and uterine irritation frequently produce 
strong sympathetic influences on the teeth, and espe- 
cially on those which are in an irritable condition. Even 



CONDITIONS TO BE OBSERVED IN EXTRACTION. 431 

sound teeth may be thus affected, so as to occasion 
great annoyance. Such teeth are frequently presented 
for extraction ; but these cases should always be thor- 
oughly examined before deciding as to the propriety 
of an operation. As a consequence of this sympathetic 
connection between the teeth and the uterus, the latter, 
when in an irritable condition, is very liable to be af- 
fected by any special violence to the former. In many 
cases, under such circumstances, the extraction of a 
tooth is attended with pain in the uterus; and in cases 
of pregnancy, where there is debility of the parts in- 
volved, abortion may follow the operation. It is the 
duty of the patient, under such circumstances, to notify 
the operator of the condition, or if the latter has any 
knowledge of it, it is his duty to become fully ac- 
quainted with the circumstances, and then to conform 
to the indications. In such case, treatment will avail- 
but little to prepare the system for the operation. The 
better method is to adopt palliative treatment, which, 
if the affection is wholly sympathetic, must be directed 
to the organ producing the difficulty. But if the af- 
fection is in part local, then topical treatment is also 
indicated. When there is a suppression of menstrua- 
tion, there will be an increased disposition to haemor- 
rhage ; and in the extraction of the teeth of a patient 
of hsemorrhagic diathesis, this is a point to which 
attention should be very specially directed. Here, of 



432 EXTRACTION OF TEETH. 

course, a remedy for the obstruction would meet the 
difficulty. 

Persons subject to epilepsy should be very cautiously 
treated in all operations on the teeth, and most espe- 
cially in their extraction. It is not probable, how- 
ever, that an operation of this character would increase 
the tendency to epilepsy ; but any undue excitement 
is liable to produce a paroxysm of the disease, and 
hence the operator should proceed to his work with as 
little parade as possible, yet not stealthily ; the patient 
should be thoroughly aware of what is to be done ; 
for, of all patients, such a one is the last that should 
be deceived. Of course, in a case of this kind, there 
can be no prior treatment that will avail anything ; 
the most that can be done is, to await the fittest oppor- 
tunity in respect to the paroxysms. There is no more- 
liability to fatal results with such patients than with 
others.. 



CHAPTER XII. 

ACCIDENTS IN THE EXTRACTION OF TEETH. 

The accidents liable to occur to the teeth and the 
contiguous parts in the operation of extraction are 
much less frequent and serious than formerly. This 
results from the existence of more perfect instruments 
and of more accurate and extensive knowledge. 
Formerly, very few studied the peculiarities of the 
teeth, either in their physical or anatomical structure ; 
their peculiar forms as indicated by their crowns ; 
their anatomical and physiological relations to the 
contiguous parts, and to one another; and their at- 
tachment as affected by the character and structure 
of the tissues about them. The instruments em- 
ployed, too, were, till within a few years past, very 
crude in their forms, very inapplicable in that part 
which embraces the tooth, inappropriate in their 
shapes, and defective in their manner of applying 
the force in the operation. But these causes of acci- 
dents, so far as the better part of the dental profes- 
sion is concerned, have been in a very marked degree 
diminished. 

Some of the accidents attendant or consequent on 

28 



434 ACCIDENTS IN THE EXTRACTION OF TEETH. 

the extraction of teeth are of a grave character. 
Permanent deformity has sometimes been occasioned 
by extensive laceration of the soft parts, or by frac- 
ture of the alveolus and of the maxilla. Intense and 
protracted suffering frequently, and death sometimes, 
follows such accidents. 



HEMORRHAGE. 

Excessive and obstinate haemorrhage in some cases 
follows the extraction of teeth, occasionally resulting 
seriously and even fatally. There is in some consti- 
tutions a hsemorrhagic diathesis, so that from a small 
wound, or even a scratch, there will ensue persistent 
bleeding. This condition is dependent, first, on a 
lack of tone in the bloodvessels, so that they fail to 
contract at an injured or ruptured point; and sec- 
ondly, on a peculiar condition of the blood, such as 
to prevent ready coagulation, as when there is a rela- 
tive deficiency of albumen and fibrin. It is one of 
the most important duties that ever devolve on the 
dentist, to make a correct diagnosis in cases where 
there is a tendency to haemorrhage. Close attention 
to the following points will assist much in arriving 
at a just conclusion. In persons of a hsemorrhagic 
tendency there is a lymphatic, serous temperament; 
a lack of tone in the soft parts, a soft flabby condi- 
tion ; the skin pale, and devoid of the bright, vital 



HEMORRHAGE. 435 

appearance ; the eyes and hair of light color ; and 
the flow of saliva and mucus abundant. Besides these 
indications, much may be learned sometimes by 
properly-directed inquiries of the patient in regard 
to a disposition to haemorrhage on being wounded, 
either in his own case, or in that of his relatives ; if 
in the former, under what circumstances; whether 
from an extensive or slight wound; from large or 
small vessels, from arteries or veins ; or whether it 
occurred immediately or after the lapse of some time. 
If the patient has never met with an accident suffi- 
cient to occasion excessive haemorrhage, and any of 
his relatives have, and a tendency to bleeding is 
suspected in the case, the operator should ascertain 
whether there is a similarity of temperament and 
constitutional tendencies between the patient and 
such relative. 

There are certain conditions in which excessive 
haemorrhage would be more likely to occur than in 
others ; as, for instance, when there is an accidental 
relaxation, or deficient tone in the system, especially 
the vascular; and also when there is a suppression 
of any periodical discharges. There may be exces- 
sive haemorrhage from a ruptured vessel when there 
is no constitutional hemorrhagic tendency. There 
is sometimes a local difficulty with the vessels — a 
lack of tone in the part — or an aneurysmal condition 
— on account of which obstinate haemorrhage will 



436 ACCIDENTS IN THE EXTRACTION OF TEETH. 

occur. A peculiarity of this kind is not very readily 
recognized. 

Violent passion, and, indeed, any strong agitation 
of the mind, will aggravate haemorrhage. Improper 
medication, as well as highly stimulating food, will 
have the same tendency. Anything that will in- 
crease the circulation, or reduce the tone of the 
vessels, or change the condition of the blood, will 
increase the liability to haemorrhage. Simple deter- 
mination of blood to a part, however, would not 
indicate such a liability. When there is a special 
haemorrhagic diathesis, the blood will flow from all 
the wounded surface, will be thrown out from all the 
ruptured capillaries. The most difficult cases are 
those in which there is a defect both in the vessels 
and in the blood. If the latter is in a good condi- 
tion it will coagulate in ruptured capillaries, though 
they might be deficient in tone ; but in larger vessels, 
though coagulum might be formed, it would hardly 
be retained. 

Treatment. 

In cases where there is manifest haemorrhagic dia- 
thesis, prior treatment is indicated, if the necessity 
of extraction is not urgent ; and that treatment will 
be determined by the peculiar condition of the case. 
If there is a lack of tone in the vessels — an inability 
to contract — then the treatment should be of a tonic 



HEMORRHAGE — TREATMENT. 437 

character ; and if the blood is in good condition, this 
is the only treatment necessary ; but, if in a vitiated 
state, other treatment will be demanded, the object 
of which is to produce an increase of red corpuscles, 
albumen and fibrin. It is always better to postpone 
an operation, if at all practicable, till such treatment 
can be had as will bring the system to the best possi- 
ble condition. 

Of the several methods of arresting haemorrhage, 
the proper one in a given case will be determined by 
the circumstances. Styptics or astringents applied 
directly to the ruptured surface will often be found 
to produce coagulation of the blood, and thus stop its 
flow without anything else. This kind of remedy 
will be efficient in those cases in which the applica- 
tion will produce contraction of the bleeding vessels, 
as well as coagulation of the blood. Sometimes this 
class of agents will fail to accomplish the object ; in 
which case, in addition to them, compression should 
be made upon the part. Indeed, in many cases, the 
compress will effect all that is desired, without any 
other application. 

There are several methods of applying the com- 
press ; but the one best adapted to any given case 
will be determined by circumstances — such as the 
extent of the wound, the character of the hemor- 
rhage, the location of the injury, and the size of the 
mouth. 



438 ACCIDENTS IN THE EXTRACTION OF TEETH. 

A very common method of making compression in 
the socket from which a tooth has been drawn, is to 
force into the cavity pledgets of cotton, or small 
strips of linen, tightly till it is full. It is well to 
saturate these with a solution of tannin, or some 
astringent preparation, applying it, too, in connection 
with the compress. In some cases, a simple packing 
of the cavity in this manner is quite sufficient, but 
in others it is necessary to retain the pledgets in the 
socket by means of further compression. This is 
effected by placing a roll of linen, or perhaps bet- 
ter, a properly formed piece of cork, on the packing, 
and then closing the jaws tightly upon this, and, if 
need be, placing a bandage under the chin, and tying 
it firmly over the head. The length of time during 
which it will be necessary to keep the jaws thus 
together will, depending on the nature of the case, 
be from one to six hours. After the haemorrhage has 
entirely ceased, the bandage is to be removed care- 
fully, and the patient instructed to hold the jaws 
together on the compress for a time and then gradu- 
ally to open the mouth, and remove the cork with 
much caution. After this the packing should re- 
main in the socket from one to three days, and then 
be removed very carefully, one piece at a time, lest 
the ruptured vessels be opened and the haemorrhage 
caused to recur. 

The object in applying a compress is to bring it to 



HAEMORRHAGE TREATMENT. 439 

bear upon the aperture of the wounded vessel, and in 
this way to prevent the escape of blood, till coagulum 
is formed and the opening permanently closed. The 
operator should ascertain the precise point from which 
the blood flows, and form the compress so as to bear 
directly upon it. If the flow is from all the wounded 
surface, then the compress must be made to conform 
exactly to that throughout. 

Another method of making the compression, is to 
force softened wax into the socket, so as to fit it per- 
fectly ; remove it and chill it in cold water ; and then 
introduce and make compression upon it in the man- 
ner already described, following throughout the gen- 
eral directions. Another, and probably better, me- 
thod is to form cones of wax cloth, as near the shape 
and size of the root removed from the socket as pos- 
sible. This material is prepared by dipping thin 
linen into melted beeswax, withdrawing it and let- 
ting it cool, and then cutting off strips of from a 
fourth to half an inch wide, and rolling them to the 
proper size and shape ; having softened this material 
by heat and freed the socket of coagulum, introduce 
and press it firmly into place, making the compression 
on it as already directed. This makes a very efficient 
compress for many cases. 

Plaster of Paris is sometimes used on the principle 
of a compress. Having the plaster mixed of the 
proper consistence, and the cavity clear, fill com- 



440 ACCIDENTS IN THE EXTRACTION OF TEETH. 

pletely with it, let it set, and then make compression 
on it in the usual manner. 

The root of the tooth is sometimes returned to the 
socket, to serve as a compress. It possesses the ad- 
vantage of having a perfect adaptation. This me- 
thod of compression may be made more thorough 
by immersing the root in melted wax, and then, be- 
fore this becomes too hard, introduce it into its orig- 
inal position. This makes a very perfect and effi- 
cient compress. If the crown is still remaining, when 
the jaws are closed it will come in contact with the 
opposing teeth, and thus be kept firmly in place, with- 
out anything further. It may be removed carefully 
after from one to three days. In cases where there 
is haemorrhage from the entire wounded surface, there 
will be a considerable flow of blood from the margin 
of the gum, even after plugging up the socket, and 
making compression by either of the methods de- 
scribed. In such case, after the socket is plugged up 
as already described, a plate is so formed as to fit 
tightly over the gum, and draw its margin down 
closely upon the compress. This pressure on the 
bleeding edges of the gum checks the flow of blood 
there. The plate must be held down by the means 
already described. It is sometimes difficult to obtain 
an accurate fit for the plate, so as entirely to pre- 
vent the blood from continuing to ooze out. In such 
cases, make the plate to conform as nearly as con- 



HEMORRHAGE — TREATMENT. 441 

venient to the part; then fill up its concavity with 
plaster of Paris, mixed to a proper consistence, and 
then place the whole upon the part, till the plaster 
conforms exactly to it, and retain it there till the 
plaster sets. This is then used for the compress. Or 
the inside of the plate may be thickly coated with 
softened gutta-percha, instead of plaster, and pressed 
upon the part in the manner already described, and 
employed in the same way. 

It will often require considerable discrimination to 
determine the best method of obtaining compression. 
Great difficulty is occasionally experienced when a 
portion of the process has been broken away, or the 
soft parts have been lacerated. 

Various preparations are used as haemostatics. 
These agents serve to check haemorrhage in two 
ways : first, by facilitating coagulation of the blood; 
and secondly, by producing a contraction of the ori- 
fice of the ruptured vessels. It is proper, in all cases, 
to use styptics in connection with the compress. 
The following agents have been used as styptics : 
tannic acid, creosote, nitrate of silver, chloride of 
zinc, sulphate of zinc, oil of turpentine, muriate 
of iron. The methods of applying these different 
preparations are the same. The agent is simply 
to be retained in contact with the part till it has 
exerted its influence. A solution of tannin in alco- 
hol, with creosote, equal parts, makes a very power- 



442 ACCIDENTS IN THE EXTRACTION OF TEETH. 

ful styptic; or tannin and creosote alone is perhaps 
equally efficient. 

The actual cautery is sometimes used to arrest 
haemorrhage, but the propriety of using it in cases 
where there is a manifest hemorrhagic diathesis is 
exceedingly doubtful. When the cauterized surface 
is sloughed off, the haemorrhage is liable to recur with 
increased vigor, indeed, is certain to do so in almost 
every case where there is a strong predisposition. 
Constitutional treatment may be employed to antici- 
pate haemorrhage; and it should have in view an 
increase of the relative amount of red corpuscles, 
albumen, and fibrin in the blood, and also the pro- 
duction of a normal tone of the system. Saline pur- 
gatives may be used with very decided advantage, 
followed by acetate of lead in connection with opium, 
the eifect of the lead being to increase the coagula- 
bility of the albumen and fibrin. Care should be ex- 
ercised, however, in its administration. 

Excessive haemorrhage will sometimes occur from 
very slight wounds ; death has been known to ensue 
from simply scarifying the gums. 

Mr. C. desired the removal of the first superior 
molar. The gum was separated from the neck of the 
tooth with the lancet, in the usual manner, when he 
refused to have anything further done, and left the 
office, there being a slight discharge of blood from 
the gum. After a few hours the haemorrhage in- 



HEMORRHAGE — TREATMENT. 443 

creased so as to cause alarm to his friends. The 
patient was about eight miles from a dentist, and a 
physician of rather moderate skill was called to the 
case. He probably acted according to his best 
knowledge, but failed to arrest the haemorrhage, and 
succeeded in convincing the friends that no one else 
could do better. The flow of blood continued three 
to four days, proving wellnigh fatal, but at last 
abated, and the patient recovered. In this case, a 
properly-directed compress would have checked the 
bleeding in a few minutes. 

Another case : Mrs. T. had nine teeth removed. 
The operation was not followed immediately by un- 
usual haemorrhage, but within two or three hours 
the flow of blood had increased to an alarming ex- 
tent, so as to run from the mouth in a continuous 
stream. The indications were that the patient would, 
soon die. She had become very weak. On examina- 
tion, the blood was found issuing, only from the socket 
of one root of an inferior molar. The mouth and 
socket being cleansed of blood and coagulum, it was 
perceived that the haemorrhage was from a small ar- 
tery at the bottom of the socket, spouting out in jets- 
with the pulsations. The treatment consisted in 
rolling up pledgets of cotton very tightly, saturating 
them with creosote and tannin, and forcing them in 
on the bottom of the socket^ so as to make compres- 
sion upon the bleeding vessel. The socket was then 



444 ACCIDENTS IN THE EXTRACTION OF TEETH. 

filled, compression made, and the head bandaged in 
the manner already described. Thus the hgemor- 
rhage was immediately checked and did not return. 
This patient was of a scorbutic diathesis. 

Excessive bleeding often does not occur till a con- 
siderable time after an operation, and it may come 
on without any exciting cause, or be induced by 
vigorous muscular exercise, or by any intense men- 
tal excitement. Everything of this kind should be 
avoided where, there is a predisposition to haemor- 
rhage, and everything invited that would tend to 
maintain the equilibrium of the circulation and the 
utmost quiet. 

Fracture of the Alveolus. 

The ordinary fracture of the alveolus is a matter 
of no considerable consequence, if it receives proper 
attention. This fracture occurs to a greater or less 
extent under the following circumstances : 

First. When there is great divergence of the roots, 
so that the tooth cannot pass from its socket, unless 
one or more of them are broken off, or the alveolus is 
fractured. 

Second. Where the tooth is forced out of the 
socket at a very considerable angle with its axis. 

Third. Where the alveolus is very firmly attached 
to the roots, and is very thin toward the point of 
these. 



FEACTUEE OF THE ALVEOLUS. 445 

Usually, the fracture is of that part which forms 
the socket of the tooth removed ; and when this is 
the case, it is of but small moment. It sometimes, 
however, extends far beyond this, involving the al- 
veolus of from one to four of the adjacent teeth, and 
causing very serious injury, even the loss of the teeth 
themselves. Extensive fracture, however, is far less 
liable to occur now than when less perfect instruments 
were employed. When the key was in general use, 
extensive fracture of the alveolus was frequent ; but 
with the forceps, it is comparatively rare. 

When an accident of this kind does occur, all of 
the detachecl portion, whether large or small, should 
be removed. A pair of bone nippers, or enucleating 
forceps, will answer for this purpose. If there is 
much attachment of the soft parts, it should be dis- 
sected off, and then removed. If such fractured por- 
tions are permitted to remain, inflammation, and 
oftentimes sloughing of the gums, will ensue ; necro- 
sis of the bone is also sometimes produced by detached 
bone remaining in contact with the living. 

Sometimes extensive fracture occurs, involving the 
adjacent bony structure. In the case of Mr. W., in 
an effort to remove the first superior molar, the outer 
wall of the alveolus was separated from the other 
teeth. The fracture extended almost to the zygo- 
matic process, and detached a portion of the floor of 
the antrum, as well as a part of its outer wall. After 



446 ACCIDENTS IN THE EXTRACTION OF TEETH. 

the removal of this detached portion, there was a con- 
siderable external depression, that very much marred 
the form and symmetry of the face. 

Fracture of the alveolus should always be guarded 
against as carefully as possible. It always makes an 
unfavorable impression on the mind of the patient, 
which in many cases no explanation can obliterate. 
Whenever the accident does occur, the disagreeable 
knowledge of it may, if practicable, remain a secret 
with the operator. 

Laceration of the Gums. 

The gums are often bruised and lacerated with the 
key in the extraction of teeth. But this accident 
seldom happens with the forceps ; indeed, never, un- 
less the gum is very firmly attached to the neck of 
the tooth, and has not been separated with the lan- 
cet. The gum will sometimes be lacerated by adher- 
ing to a piece of the process while the tooth is drawn 
from its socket, with the process and gum attached. 
With the various hooks and punches, the gums, lips, 
and cheeks are sometimes wounded. Accidents of 
this kind are to be prevented by placing a finger of 
the left hand, or a guard made of a roll of linen, in 
front of the instrument. When any considerable 
portion of gum is lacerated, the detached portion 
should be cut offl The worst consequences from lace- 



BREAKING THE TEETH. 447 

ration of the soft parts occur where there is a heernor- 
rhagic diathesis. The most effectual means of pre- 
venting accidents of this kind is to separate the gum 
perfectly, and guard well the points of the instrument. 

Breaking the Teeth. 

This is an accident of no small consequence, and is 
liable frequently to occur in the use of imperfect, ill- 
adapted instruments, or in the unskilful use of good 
ones. It is of very common occurrence when the key 
is employed for extracting, even in the hands of those 
who claim to be skilled in its use. And with forceps, 
too, of the primitive form, the teeth were so frequently 
broken, as almost to preclude their use as extracting 
instruments. This accident usually occasions great 
pain to the patient, as well as protracts the operation, 
and diminishes his confidence in the ability of the 
operator. One such accident will create more preju- 
dice than many skilful operations can obliterate. 

In all cases where a tooth is broken, the root, if 
possible, should be removed: for if it be not, con- 
tinuous or periodical pain, inflammation, alveolar ab- 
scess, and like affections, are liable to ensue. The 
remark is often made, when teeth are broken, that 
the gums will close over the roots, and thus effect- 
ually protect them, and no disagreeable consequences 
will follow. In no ordinary case will the gums unite 



448 ACCIDENTS IN THE EXTRACTION OF TEETH. 

over even the smallest portion of root that may have 
been left in the socket. 



Removal of a Wrong Tooth. 

There is very rarely any excuse for the removal of 
a sound, healthy tooth in the immediate vicinity of a 
diseased one, unless it be in a case of those deepseated, 
hidden affections which are difficult to diagnose. It 
sometimes happens, however, that a sound tooth is 
removed ; and when a mistake of this kind is made, 
the diseased tooth should also be at once removed, 
and then, if the conditions are favorable, the healthy 
one should be immediately replaced. The circum- 
stances most favorable for such replacement are a 
good constitution in a state of health, and a normal 
condition of the mouth, especially of the gums and 
mucous membrane, so that the attachment would take 
place with as little inflammation and soreness as 
possible. If the tooth is necessarily kept out of the 
mouth many minutes, it should be placed in water at 
about blood heat ; and before the replacement, the 
socket should be thoroughly cleansed of coagulum. 
The tooth is then introduced, pressed firmly to place, 
and allowed to remain, without disturbance or irrita- 
tion, till the attachment has become complete. Dur- 
ing the time it is reuniting, treatment may be required 
to counteract inflammation. Meagre diet, abstinence 



REMOVAL OF A WEOXG TOOTH. 449 

from stimulants, and quiet, should always be recom- 
mended in the case. 

This operation has been wholly condemned by some 
very good dentists. Dr. Koecker declares that it 
should never be attempted. But numerous success- 
ful cases, well attested, give assurance that it may 
very frequently be accomplished with the most satis- 
factory results. Mr. T., aged fifteen years, of good 
constitution, and in good health, and with the mouth 
principally in a normal condition, had the second 
inferior bicuspid of the left side removed by mistake, 
the first molar being the offending tooth. The former 
was at once put into cold water, and the latter forth- 
with extracted. The socket of the biscuspid was then 
cleansed, and the tooth replaced. There was slight 
soreness for a few days, after which the tooth was 
found to have made a firm and permanent re-attach- 
ment, and from that time to this — thirty-eight years 
— it has remained perfect, and is now as healthy, life- 
like, and valuable as any other tooth in the mouth. 

Since the issue of the first edition of this work, 
many cases have come under the observation of the 
writer in which detached teeth have been replaced, 
and become as firmly fixed in the socket as before re- 
moval, and remained in apparently a healthy condi- 
tion so far as the attachment is concerned. In some 
of these cases very unfavorable conditions were 
present. 

29 



450 ACCIDENTS IN THE EXTRACTION OF TEETH. 

So numerous and successful have these cases been, 
that the feasibility of replacing teeth that have been 
removed is a matter no longer to be controverted, and 
especially when favorable conditions exist — good 
health and tone, both general and local, and the parts 
involved not too much fractured or lacerated. 

Dislocation of the Inferior Maxilla. 

The dislocation of the inferior maxilla is an acci- 
dent of not very frequent occurrence. In persons of 
lax muscles and with large mouths, the operation of 
extracting teeth is liable to produce it — sometimes 
when the operation is on the upper jaw, but more 
frequently when it is on the lower. In the former 
case, it is a result of the patient's effort to open the 
mouth ; but in the latter, generally that of the move- 
ment of the jaw by the instrument. The dislocation 
consists in a downward and forward movement of 
one or both of the condyles, so that they are thrown 
out of their sockets, and rest in front of the anterior 
rim. In such case, the mouth is distended to its ut- 
most, the chin thrown down on the breast, and deg- 
lutition and speech rendered impossible. Sometimes 
but one condyle will be thrown out, in which case 
the jaw is thrown downward and to one side. 

This accident seldom or never occurs with patients 
who have small mouths or firm muscles. When it 



DISLOCATION OF THE INFERIOR MAXILLA. 451 

does happen, however, the dislocation should be 
promptly reduced. Of the various methods of accom- 
plishing this reduction, the one most commonly em- 
ployed, which is very efficient, is as follows : If both 
condyles are dislocated, place corks or some similar 
substance between the superior and inferior molar 
teeth of both sides, and then, with the fingers of 
both hands, make firm, steady pressure on the chin 
upward and backward, thus forcing the condyles 
downward and backward into their proper place. 
If but one condyle is out, the cork should be ap- 
plied only on that side, and in the manner already 
directed. Another method is, to substitute the 
thumbs of the operator for the corks, placing them 
in the same position between the teeth, and manipu- 
lating with the fingers on the chin, as before. The 
patient should be placed in a recumbent position for 
the operation. Another method is, to make down- 
ward and backward pressure on the coronoid process, 
and in this manner cause the condyles to glide into 
their places. This accomplishes the reduction with- 
out taking hold of the jaws, or placing a fulcrum 
between them. 

This accident is far more liable to occur the second 
time in the same case. In extracting the lower molar 
teeth for a person who has suffered a dislocation, or 
is predisposed to it, the lower jaw should be very 
firmly supported with the left hand; or the accident 



452 ACCIDENTS IN THE EXTRACTION OF TEETH. 

may be prevented by placing a bandage under the 
chin and over the head, so that the mouth cannot be 
opened to its furthest extent ;. and this is the surest 
method. In all cases after an accident of this kind, 
the patient should abstain from solid food for a few 
days, or at least till the soreness is abated, and avoid 
everything promotive of inflammation. 

Syncope. 

Syncope, or fainting, is frequently brought on by 
extraction of the teeth, and even by other operations 
upon them ; indeed, it is sometimes produced simply 
by cutting the gums, or by the sight of blood, or, in 
some instances, by dread of an operation. It con- 
sists in an intermission of the heart's action, and 
consequent irregularity of the circulation, accom- 
panied with a temporary suspension of the functions 
of the brain, and a loss of consciousness. Difficult 
or suspended respiration, pallor of the skin, and ina- 
bility to move, are the external indications of the 
condition. There are no constitutional appearances 
known by which a predisposition to syncope can be 
determined. Persons of all apparent conditions and 
peculiarities are subject to it. The most strong, ro- 
bust, and healthy sometimes faint under the most 
trivial influences, while others, of the weakest and 
feeblest constitutions, cannot be brought into this 



■syncope. 453 

condition by any ordinary means ; so that nothing 
can be predicated of appearances as to such predis- 
position. The fainting may occur once or twice in 
the same case, even under the most simple operation, 
owing to some temporary condition of the system, 
and never happen again under any circumstances 
wmatever. 

It sometimes comes on before, sometimes after, and 
sometimes during the operation. There is greater 
liability to it after a recent meal than after digestion 
is completed, since the nervous energy during diges- 
tion is directed to the stomach and its appendages, 
and thus the circulatory apparatus has less of nervous 
force. 

The frequent occurrence of syncope indicates a 
constitutional predisposition to it, and may enable 
the operator to anticipate it to some extent, by the 
aid of stimulants, such as brandy, or, what is, in 
some respects, preferable, a galvanic current. The 
patient subject to such affection should be placed, 
for an operation, as nearly as practicable in a recum- 
bent position, — especially for the extraction of teeth, 
— and his mind kept as tranquil as possible. 

To restore the patient from syncope, place him in 
a horizontal position, the head quite as low as the 
body, and apply volatile stimulants to the nostrils, 
and dash water on the face and chest. All compres- 
sion should be removed from the body, especially 



454 ACCIDENTS IN THE EXTKACTION OF TEETH. 

from the chest, as it would constrain the action of 
the respiratory muscles. This remark is peculiarly 
applicable to female patients. This treatment will 
usually be quite sufficient to effect a rapid reaction 
and resuscitation. 



CHAPTER XIII. 

anesthetics. 
Ether — Chloroform — Nitrous Oxide. 

Sulphuric Ether was the first agent successfully 
employed for producing insensibility to pain during 
surgical operations. It was brought to the notice of 
the profession in 1846, by the late Dr. Horace Wells, 
of Hartford, Conn. 

The mode of administering it is by inhalation of 
the vapor, and it produces its effects in a short time, 
depending on the quality of the ether, the amount of 
air introduced with it, and the susceptibility of the 
patient. A complicated instrument, denominated an 
inhaler, was first employed for its administration, 
but it soon became apparent that this was not at all 
necessary, and that simpler methods were preferable, 
because more easily regulated and adapted to vary- 
ing circumstances. The best method is to inhale it 
from a sponge or napkin, since in this way the ad- 
mission of the air can be controlled entirely by the 
will of the operator, graduating it to the require- 
ments of the case. 

During the administration, the patient should be 
in a reclining posture, though it is held, by good au- 



456 ANESTHETICS. 

thority, that a horizontal position is the safest, be- 
cause in that the force of the circulation is most 
nearly equalized. In the administration of general 
anaesthetics the circulation is always more or less af- 
fected. It is an opinion very generally received, and 
probably correct, that where there is functional de- 
rangement of the heart, lungs, or brain, general an- 
aesthesia should not be employed. This opinion, 
however, is, perhaps, derived more from analogy than 
from actual observation. It is true that, other things 
being equal, the liability to injury in such case would 
be greater, but the danger with both ether and chlo- 
roform is, that there are cases in which there is an 
undefinable and undetectable idiosyncrasy, or mal- 
susceptibility to its influence, to a great extent inde- 
pendent of pathological conditions. 

The patient having been placed in a comfortable 
position, and his mind freed as far as possible from 
apprehension, he should be directed to breathe tran- 
quilly by full inspirations, carefully guarding against 
any compression of the chest, so as to allow the re- 
spiratory muscles free play. During the administra- 
tion of the anaesthetic a strict watch must be main- 
tained over the patient, having reference to the fol- 
lowing points: The breathing should be free and 
easy, without irritation of the throat or bronchia ; the 
skin should not become blanched, but should retain 
a florid, lively color; but the great criterion is the 



ETHER — CHLOROFORM. 457 

pulse, and the indications given here should be strict- 
ly observed and obeyed. In order that the operator 
may follow every indication, he should be familiar 
with the manifestations of the pulse in different con- 
stitutions and under different circumstances. During 
the administration of ether or chloroform, the pulse 
usually becomes more frequent ; but it should not be 
much accelerated, nor its strength and fulness be 
much diminished. Feeble or irregular pulse should 
in all cases be regarded as a warning ; and if the 
feebleness and irregularity be very marked, the ope- 
rator should desist. In some instances death has 
occurred after a few inhalations ; but perhaps only in 
the use of chloroform. This fact indicates that the 
first effects of the administration should be very closely 
noted. 

The degree to which the anaesthesia should be car- 
ried is a matter about which there is much diversity 
of opinion. Every condition of it, from that of sim- 
ple allayed irritability to that of complete insensibil- 
ity and unconsciousness, has its advocates. But the 
extent to which the administration may be carried 
will be suggested by the indications already referred 
to, and, if these are unfavorable, should be deter- 
mined at once. Mere nausea, however, without any 
other unfavorable symptom, is not a counter-indica- 
tion in the use of ether or chloroform. 

The method of administering chloroform is the 



458 ANESTHETICS. 

same as that for ether, except that in the use of the 
former more care and closer observation are required* 
Chloroform is more rapid and powerful in its action 
than ether, and hence more liable to do injury ; but, 
independently of this fact, it is generally believed 
that the former is less safe than the latter, when taken 
into the system, especially by inhalation. A mix- 
ture of ether and chloroform, or chloric ether — usu- 
ally equal parts of chloroform and ether, but the pro- 
portions are sometimes varied — is used by some, the 
object being to secure greater promptness than with 
ether alone, and incur less danger than with chloro- 
form ; and it is probable that a mutual compensation 
in these respects is thus to be attained. 

If either chloroform or ether has been administered 
to entire unconsciousness, the patient should be per- 
mitted to pass out of the condition spontaneously ; 
for after such a revival there will be less liability to 
unpleasant feelings, as headache, depression, and nau- 
sea. The fingers of the person administering the 
chloroform should be kept on the carotid, since the 
state of the circulation will be better recognized by 
this than by the radial artery, and it is a more con- 
venient point for observation. In favorable cases, it 
is preferable to continue the inhalation till there is 
muscular relaxation. 

When a condition arises in which respiration is 
suspended, and the circulation partially or altogether 



NITROUS OXIDE. 459 

stopped — a condition of imminent peril — active mea- 
sures must be resorted to for the patient's restoration. 
Efforts must be directed to a recovery of the circula- 
tion, by friction, motion, etc. ; but to restore the res- 
piration is the first, immediate, imperative considera- 
tion. Any or all of the ordinary methods of re-estab- 
lishing suspended respiration may be employed. Cold 
water should be dashed in the face, and on the throat 
and chest, and volatile stimulants applied to the nos- 
trils ; the glottis should be titillated with a feather, 
or some such implement, to excite it to action ; and 
artificial respiration, by some approved method, should 
be at once adopted. The galvanic current, too, may 
be brought into requisition, to excite the respiratory 
muscles to action, and to act also upon the circulation. 
In all cases of accident of this kind, prompt and effi- 
cient measures should be immediately taken, for a 
delay of a few moments may be attended with fatal 
results. 

Nitrous Oxide. 

Nitrous oxide is now used as a general anaesthetic 
quite extensively in dental practice. This agent, 
when properly prepared and judiciously administered, 
is perhaps the safest general anaesthetic in use ; it is 
very efficient for minor surgical operations, and we 
believe it will ere long be found applicable to the more 
protracted and graver operations. Its efficiency is 



460 ANESTHETICS. 

very much modified by its preparation and mode of 
administration. This gas when pure is colorless, and 
of slightly sweetish taste and odor ; it is usually pre- 
pared by decomposition of nitrate of ammonia. 

It is not the purpose here to describe the method 
of preparing this agent — that has been well done by 
others ; yet it is proper to suggest here that, to a 
large extent, the knowledge and opinions entertained 
on this subject have been very circumscribed, and ex- 
ceedingly erroneous. In the administration of nitrous 
oxide as an anaesthetic, great care should be exercised 
to secure the best results. In order to accomplish 
this, it should be inhaled, and in no case but once, 
diluted, as circumstances may indicate, more or less 
with pure atmospheric air ; this is ordinarily neces- 
sary only at the beginning, for pure nitrous oxide will 
sustain respiration for an indefinite time. 

To a patient in an anaesthetic state, it is not so 
readily administered as chloroform or ether ; but the 
patient under its influence is quite as manageable as 
with any other agent, and the anaesthesia as perfect, 
but not as prolonged without continued administra- 
tion. 

It is scarcely justifiable in ordinary dental practice 
to use a more heroic general anaesthetic than the one 
here referred to. 

Nitrous oxide gas is now prepared in liquid form, 
and may be procured of the manufacturers, ready for 



NITROUS OXIDE. 
Fig. 125. 



461 







use. There are some advantages derivable from this. 
The gas in this form is prepared by persons of ex- 
tended knowledge and experience in chemical work, 



462 ANAESTHETICS. 

which gives assurance of purity ; and, in addition to 
this, by the condensation to the liquid form, any ex- 
traneous gases are expelled, and thus there is far 
greater certainty of obtaining pure gas than when it 
is prepared in the ordinary way, and that by persons 
having little or no knowledge of chemical science or 
processes. 

The accompanying cut (Fig. 125) represents an 
ornamental, convenient and efficient gas-holder. The 
liquid gas is contained in the cylinder in the lower 
part; from this the gas escapes into the holder above, 
directly from which the gas is administered to the 
patient. A portable apparatus for holding and ad- 
ministering the gas is also constructed, which for 
some purposes is preferable to this. 

Local Anaesthesia. 

Because of the frequently prejudicial and some- 
times fatal consequences to which systemic anaesthe- 
sia is liable, local anaesthesia has been brought into 
requisition ; the first method of accomplishing this 
was by 

Congelation. — Freezing a part, to produce insensi- 
bility under surgical operations, is a process that has 
long been in use. Various methods for accomplishing 
it have been employed. There are perhaps none so 
well adapted to the dentist's use as ether spray. So 
easy of application is it, and so generally efficient, 



LOCAL ANAESTHESIA. 



463 



that it is in almost universal use. To Dr. Richard- 
son, of London, is due the credit of having brought 
this process to its present state of perfection. 

So accurately does the accompanying engraving 
(Fig. 126) represent the apparatus used in this pro- 



Fig. 126. 




cess, that a minute description is unnecessary. The 
mode of application and operation is apparent at 
once. 

The instrument consists of the fluid holder — a 
four-ounce bottle, graduated — the bellows consisting 
of a rubber ball, with the proper valves, and the 
points from which proceed the spray, and these all 
connected by the proper-sized flexible tube. 

It will be observed that there are variously-formed 
points, single and double, straight and curved ; these 
are required for the various processes to which the 
instrument is applied. 

For the extraction of teeth, the double point is 



464 ANAESTHETICS. 

applicable, throwing the jet upon the gum each side 
of the tooth at the same time. The single points 
are required where an incision or excision is to be 
made. 

This is a very valuable instrument, and is exten- 
sively used in minor surgical operations, and is espe- 
cially adapted to the dentist's use. Ether is perhaps 
as yet the best agent employed. Ehigolene, a far 
more volatile fluid than ether, has been used to a 
limited extent, but owing to its exceedingly rapid 
evaporation, its action is too violent, and not so easily 
controlled. 

For inducing local anaesthesia, various prepara- 
tions have been suggested. The following has been 
in use for several years, namely, a mixture of chloro- 
form, tincture of aconite, belladonna, and opium. 

This applied to the gums, or, indeed, to any other 
surface tissue, will in many cases very much obtund 
sensibility, and in some relieve it altogether, so that 
a tooth may be extracted, or a deep incision made, 
without pain. 

The dental pain-obtunder, which was introduced to 
the profession about eight years ago, for relieving 
sensitive dentine, is a good local anaesthetic. Another 
preparation, made and introduced by Dr. C. Yon Bon- 
horst, is also quite efficient. 

Dr. Yon B. has invented an instrument for using 
his preparation, or any other for like purpose. It 



EXTRACTION BY ELECTRO-MAGNETISM. 465 

consists of two small metallic cups, attached to the 
ends of an elongated staple, of heavy wire, about 
seven inches long. This is the handle of the appli- 
ance. 

The sponges are placed in sections of rubber tube, 
about half an inch in length, and these together are 
placed in the cups. The sponges are saturated with 
the ansesthetic fluid that may be selected, and are 
applied to the gum on each side of the tooth to be 
extracted, and retained on the part from one-half to 
two minutes; the length of time will be governed by 
the susceptibility of the part, the agent employed, 
and the extent of the anaesthesia sought. 

Entire insensibility to pain cannot thus always be 
obtained, but in many cases it can, and diminution 
of it in all cases can be effected. This appliance is 
very convenient for the purpose for which it is used. 

The following cut (Fig. 127) represents the instru- 
ment ready for use. 

Fig. 127. 




Extraction by Electro- Magnetism. 

The employment of electro-magnetism in the ex- 
traction of teeth was introduced to the profession 

30 



466 ANESTHETICS. 

about twenty-five years ago, and at one time was ex- 
tensively used. There is a great diversity of opinion 
as to its efficiency for relieving pain ; for, while some 
have been disposed to assume that, when properly 
employed, it would in the majority of cases mitigate 
pain, and in many obviate it altogether, others, after 
having thoroughly tested it, as they affirm, maintain 
that it does not produce insensibility to any appreci- 
able extent, and consequently does not relieve the 
pain, but that, at most, it only complicates the sensa- 
tions, the pain of the tooth-drawing becoming in- 
volved in the confusion of other feeling, so that the 
patient can hardly decide whether he has suffered 
pain or not. 

In using this agent for the purpose of extracting 
teeth, the susceptibility of the patient to its influence 
must be carefully regarded. Some persons are so 
peculiarity constituted that an electric current is 
almost intolerable to them, while others will receive 
a strong current with pleasurable sensations. To the 
former, the electricity would be as painful as the ex- 
traction of the tooth ; but to the latter, when properly 
applied, it mitigates, and in many cases altogether 
obviates, the pain. The reason of this difference in 
its action is not very clearly understood. Several the- 
ories in regard to it have been advanced, but none of 
them sufficiently plausible to challenge conviction. 

Again the manner in which, and the condition of 



APPLICATION. 467 

the parts to which, this agent is applied, are to be 
closely observed. Where there is acute periostitis, an 
electric current, even though feeble, would produce 
intense pain, and should not be applied ; though in 
such cases it has been suggested that an application 
of the charged sponge to the gums will produce in- 
sensibility. 

JiPPLICATION. 

The method of application is very simple. Any 
ordinary battery, of convenient form, may be em- 
ployed for this purpose. It should be uniform in its 
action, and the vibration as short as possible. The 
common zinc-and-copper battery, with the sulphate- 
of-iron solution, is perhaps the most convenient and 
safe. One pole of the battery — no matter which — is 
attached to the forceps, and the other to a handle of 
size and form convenient for the patient to grasp. To 
ascertain his susceptibility, the current should always 
first be tested on the patient, by placing the handle 
and the forceps one in each of his hands, and letting 
it on, first feebly, and then gradually increasing it till 
he experiences the sensation just beyond the elbows; 
when, finally, it is to be slightly weakened. The 
gum having been separated, the forceps, with its ap- 
pendages, is adjusted to the tooth, the connection 
made by placing the handle in the patient's hand, 
and the tooth at that moment removed. It lias been 



468 ANAESTHETICS. 

recommended by some to place the forceps on the 
tooth, and complete the circuit as above, with the 
current very feeble, and then gradually increase it 
to the proper force for the operation. In some in- 
stances, perhaps, this would be the preferable mode. 
Another method of producing insensibility by an 
electric current is, to place two moistened sponges, 
connected with the two poles of the battery, on the 
gum, one on each side of the tooth, keep them there 
a few moments, and then operate. This method, 
however, has not yet been sufficiently tested to ascer- 
tain its merits. 



APPENDIX. 



In the following pages are presented a few subjects more at 
length than is practicable or desirable in the body of the work. 

Section A consists of selections from " Watt's Chemical Es- 
says " on " Caries of the Teeth." 

This is, perhaps, the most accurate and concise presentation of 
that subject in the English language. In treating of the subject, 
it deals with established principles and with facts, and discards 
all mere hypothesis, which has commonly entered so largely into 
the discussion of the subject. A careful and thorough study of 
the subject, as here presented, is suggested. T. 

SECTION A.— DENTAL CARIES. 

It is now admitted, by all who are familiar with the subject, 
that whatever may be the predisposing causes, the immediate 
cause of dental caries is chemical action. It is well known that 
constitutional causes have much to do with this disease, both in 
producing badly-organized, defective teeth, and in eliminating or 
preparing the agents which act chemically on them. But no con- 
stitution produces teeth so defective that they undergo sponta- 
neous decomposition while retaining a vital connection with the 
general system. I am aware that a few pathologists still main- 
tain that inflammation of the bony texture of the teeth is liable 
to the same terminations as inflammation of ordinary bony tissue, 
but it is not profitable to debate this point in the present paper. 
Suffice it to say that the structure and position of the enamel 
indicate that the danger is from without, not from within. 



470 APPENDIX. 

As soon as it is admitted that decay of the teeth results from 
chemical actiou, it is natural to inquire what agent or agents pro- 
duce this action. Accordingly, we find the profession turned at 
once in this direction. And when the composition of the teeth is 
taken into the account, we would infer that the deleterious agents 
are to be looked for among the acids. And here we have had 
great confusion of ideas, and are still likely to have it. For ex- 
ample, we are told " that it is proven that nearly all the acids, both 
mineral and vegetable, act readily upon the teeth." (Harris's 
Dictionary, article " Caries of the Teeth.") Upon any part of the 
teeth ? Or, are we to understand that some of them act on the 
animal portion, some on the earthy, and some, or all, on the en- 
amel ? Just turn to the index of almost any chemical textbook, 
and ask yourself if it is proved that nearly all of the acids there 
named act readily upon the teeth. Do carbonic acid, tannic acid, 
and scores of others that might be named, act readily upon the 
teeth? This expression, and many others that might be quoted 
from various writers, show a professional longiug for, rather than 
an attainment of, the truth in regard to this matter. 

Now. for convenience, let us assume that dental caries is pro- 
duced by the action of acids. The question still arises, what 
acids? Are many acids, or only a few, concerned in its produc- 
tion ? One of the laws of combination teaches us that chemical 
compounds are definite in their nature. Chemical action is always 
definite. When an acid combines with an alkali, or base, a defi- 
nite compound, called a salt, is formed. When a different acid 
unites with this same base, a different salt is. formed. Each salt, 
each chemical compound of any kind, is distinguished from all 
others by characteristics peculiar to itself. It is unlike all other 
substances, in some respects. Each chemical result differs from 
all other chemical results. Of course, then,, a great variety of 
chemical reagents will produce a great variety of chemical re- 
actions. 

Let us now inquire as to the various characteristics of those 
chemical actions which result in what we recognize as dental 
caries. Do we here find a great variety of appearances? Or, is 
it not well known that the phenomena of caries are so few and so 
circumscribed that, by common professional consent, but three or 



DENTAL CARIES. 471 

four varieties of it are recognized ? We find one variety often 
called "white decay," and another that is brownish in color, and 
a third that is very properly designated as " black decay." These 
differ in other respects as well as in color. In the white variety 
all the components of the teeth are acted on, and disintegrated, 
as far as the disease extends. In the second variety, the earthy 
portion of the teeth seems to be removed, while much or all of 
the animal portion remains, which is conclusive evidence that 
the chemical agent, whatever it may be, forms soluble compounds 
with the earthy materials. In the " black decay " there is less 
disintegration of the tooth substance than in either of the other 
varieties ; and it progresses less rapidly than either of them. The 
physical characteristics of this variety, aside from the chemical, 
would indicate that the chemical agent principally concerned in 
its production forms, mainly, insoluble compounds with the con- 
stituents of the tooth. Then, there is a fourth variety, commonly 
called "chemical abrasion," in which the entire tooth-substance 
is removed, as far as the disease extends. It is evident that the 
agent producing this dissolves, or forms soluble compounds, with 
both the animal and earthy materials of the tooth. 

Unless we conclude that chemical compounds are not definite 
in their nature, and that many reagents may produce but a few 
reactions, we are forced to the conclusion that dental caries, as 
observed and recognized, results from the action of but few sub- 
stances on the teeth. It is very probable that each distinct variety 
is produced by the action of a single agent, and invariably by the 
same agent. I am well aware that more than one variety may 
be found in the same mouth at the same time, and in close prox- 
imity ; and, consequently, any given case of caries may partake 
of the characteristics of more than one variety. It is not uncom- 
mon to find " white decay " attacking a tooth in a cavity pri- 
marily affected with the brown or colorless variety. But every 
practitioner is familiar with unmixed cases, representing all the 
four classes specified. 

The physical characteristics of decay depend much on the tex- 
ture of the teeth affected, but they are dependent, also, on the 
nature of the compounds formed by the union of the destroying 
agent with the constituents of the teeth. The degree of conceu- 



472 APPENDIX. 

tratiou of the chemical agent has also a modifying influence. 
When much diluted, its action is almost solely in obedience to its 
strongest affinity. For example, if nitric acid were the agent, 
when concentrated it would act energetically on the animal as 
well as on the earthy materials of the teeth, but when much di- 
luted its action would be almost confined to the latter. 

The chemical characteristics of decay, however, depend almost 
exclusively on the character of the agent producing it. The truth 
of this appears evident when we reflect that bad teeth and good 
ones are composed of the same chemical substances. Marble and 
chalk are alike in chemical composition, but not in physical struc- 
ture, and though an acid acts more rapidly on the latter than on 
the former, yet the result of the action is the same. An acid, 
too, will act with more energy on a soft, porous tooth than on 
one of firmer texture, yet the chemical results are the same. It 
is safe to conclude, then, that as there are but few results in the 
chemical actions attendant on dental caries, there are but few 
chemical agents immediately concerned in their production. 

It is not to be inferred from the above that but few agents are 
capable of injuring the teeth by chemical action. Many acids 
used in food, or as medicines, are capable of doing injury to the 
teeth. But no one need suppose that an acid, even though con- 
siderably concentrated, brought occasionally in contact with the 
teeth, is the immediate cause of caries. Every close observer will 
conclude that caries is the result of an agent acting slowly and 
steadily in the accomplishment of its work. He will be apt to 
infer that this agent is either formed by chemical action within 
the mouth, or is eliminated therein, either as a secretion or an ex- 
cretion, and that it quietly performs its disastrous deeds as fast as 
formed or eliminated. The application to the teeth of an acid 
capable of acting chemically on them, facilitates or predisposes 
to the production of caries, and this it may do without this acid 
being the immediate cause of the decay. A tooth may be frac- 
tured, or its enamel removed, by mechanical means, and, as the 
dentine is thus exposed, the tooth is more liable to caries than 
before the exposure. But no one supposes that the mechanical 
action which exposes the dentine is the immediate cause of the 
caries. The dentine would remain sound and healthy did not 



DENTAL CARIES. 473 

some chemical agent attack it. In like manner, in the adminis- 
tration of acids as food or medicine, the teeth may be so corroded 
as to expose the dentine and render it as liable to the action of 
the carious agent as in the former case ; or, if the dentine is not 
exposed, the enamel may be roughened, either mechanically or 
chemically, so as to afford a lodgment for organic matter, which, 
by decomposition, may generate one of the acids immediately 
concerned in the production of caries. On this principle, acid 
medicines and acid foods may indirectly, but not immediately, 
cause caries. The same remarks will apply to acids brought in 
contact with the teeth by eructation or vomiting. 

If this view is correct, the investigation of the subject of dental 
caries is brought within a narrower compass than many suppose. 
The first step is to inquire what acids, in health and disease, are 
liable to be secreted or excreted, so as to be brought regularly in 
contact with the teeth. The second is to ascertain what acids are 
liable to be formed within the mouth by fermentation or otherwise. 
And the third is to discover what ones of all these are capable of 
producing the phenomena of dental caries. There is but little 
room to doubt that, at least, each of the first three varieties is the 
result of a specific agent. 

To properly understand any chemical action to which the teeth 
are subject, it is necessary to bear in mind their texture and com- 
position, and to consider the chemical properties of at least their 
principal constituents. It must also be remembered that the teeth 
are endowed with vitality. As dental caries — the most common 
disease of the human race — is now universally conceded to be the 
result of chemical action, the importance of this subject is at once 
manifest. The time is not far distant when in every case of receut 
caries, the enlightened practitioner will be able, by the character 
of the decay and the habits and constitution of the patient, to 
detect and identify the agent or agents producing the disease. 
Any practice short of this knowledge must be, at least to some 
extent guesswork, and is, although the best we can now do, em- 
pirical practice. 

The fact that an active alkaline base is the principal inorganic 
ingredient of the teeth, would indicate clearly that their great 
danger lies in the presence of acids ; and all experience demon- 



474 APPENDIX. 

strates the truth of this inference. This danger is also greater 
from the fact that the principal salt of this base, present in the 
tooth -substance, combines with several acids without undergoing 
decomposition. 

It is evident that the acids do not all act alike on the teeth. 
Indeed, some exert no influence whatever on them, while others 
act with great energy on each and all of their constituents. It 
would be an endless task to consider all the substances which are 
capable of exerting an injurious chemical influence on the teeth ; 
and perhaps it would be as unprofitable as endless. All that is 
now aimed at is an accurate account of the various substances 
which ordinarily act chemically on the teeth — which produce 
caries and "chemical abrasion." 

Without further preface, we will proceed to notice some of the 
chemical agents alluded to. 

Nitric Acid. — This acid is composed of five equivalents of oxy- 
gen united with one of nitrogen. Its symbol is therefore, N0 5 . 
It acts with great energy on all the constituents of the tooth. Its 
great energy of action depends on a variety of circumstances. As 
an acid, it unites energetically with bases, and will, therefore, take 
the lime and kindred bases from the weaker acids. From its^ready 
decomposition, it affords oxygen, in its nascent condition, for the 
destruction of oxidizable substances. Its action on the tooth may 
be thus briefly described : it dissolves the phosphate of lime, de- 
composes the carbonate,, setting the carbonic acid free, and form- 
ing nitrate of lime, and destroys the organic portion, produciug 
a highly-softened state of the carious matter. In fact, it is a 
prominent, if not the principal agent in the production of the 
" white decay." 

But the question naturally arises, Is an agent so destructive in 
its tendencies likely to come in contact with the teeth, and if so, 
under what circumstances ? The question is important, and the 
answer, perhaps, difficult. 

It is well known that this acid is frequently administered as a 
tonic ; and it is a lamentable fact that far too little attention is 
paid to the prevention of its injurious effects on the teeth in such 
cases, but this will by no means account for the frequency with 
which it evidently injures the dental organs. A few thoughts in 
regard to its formation may throw some light on the subject. 



DENTAL CARIES. 475 

It is a singular fact that though nitrogen and oxygen manifest 
but little affinity for each other, yet they unite in various propor- 
tions, forming at least five well-known distinct compounds. It 
appears, however, from a variety of circumstances, that their ten- 
dency is to unite in the proportions which form nitric acid. The 
protoxide is readily decomposed, and yields nitrogen, oxygen, and 
nitrous acid. The binoxide, if brought in contact with the atmos- 
phere, takes from it two equivalents of oxygen, and also becomes 
nitrous acid, or N0 4 . Hyponitrous acid, N0 3 , on admixture with 
water, is converted into nitric acid and binoxide of nitrogen, thus : 
3N0 3 = N0 5 + 2jST0 2 , in which case the latter will be converted 
into nitrous acid, which, in the presence of water, is converted 
into nitric acid and binoxide of nitrogen. 

It follows from this that, if oxygen and nitrogen unite at all 
in the mouth, let the proportions be, at the first, what they will, 
nitric acid must be the ultimate result, as air and moisture, the 
only agents necessary in the transformation, are here always 
present. 

The reader will now think of the mucus, and particles of nitro- 
genous food lodged about the teeth undergoing decomposition, and 
yielding nitrogen to the oxygen of the atmosphere, or of the fluids 
of the mouth, and will conclude that all is explained. Well, per- 
haps it is. But let us consider. Nitrogen is emphatically a " con- 
servative " element, and manifests but little teudency to unite with 
anything and especially with oxygen. It is probable, therefore,. 
that these two elements unite indirectly. It should be borne in 
mind that organic nitrogenous bodies contain hydrogen and oxy- 
gen, as well as nitrogen. Consequently, by their decomposition, 
these elements are all liberated. The mutual affinities of hydrogen, 
and nitrogen take precedence, and the result is the formation of 
ammonia, NH 3 . But ammonia exposed to the action of oxygen is 
always decomposed; oxide of nitrogen is formed, and of course 
nitric acid is the result. 

With this view of the case, and from the fact that many persons 
permit the buccal mucus as well as particles of nitrogenous food 
to remain around, upon, and between the teeth, till decomposition 
is effected, it is not surprising that the white variety of dental 
caries is so frequently found. 



476 APPENDIX. 

Nitric acid is also sometimes formed in the mouth by the agency 
of galvanic action. When two metals are placed in the mouth in 
proximity to each other, and the fluids of the mouth are capable of 
acting on one of them, galvanic action is established. And if they 
are so situated that the mucous membrane forms a connecting con- 
ductor, by being in contact with both, especially if the metallic 
surfaces be considerable, a current is established sufficient to de- 
compose any of the binary compounds contained in these fluids. 
The liberated nitrogen, hydrogen, and oxygen will result, as above, 
in the formation of ammonia, and then nitricacid. But galvanic 
action in the mouth is more likely to develop hydrochloric than 
nitric acid. This will be noticed again. 

Sulphuric Acid. — Sulphuric acid is composed of 16 parts of 
sulphur united with 24 of oxygen. Its symbol is, therefore, S0 3 . 
In addition to those properties which characterizes it as an acid, it 
is a powerful caustic poison, and promptly destroys the various 
tissues with which it comes in contact. Its chemical action on 
ordinary tissues depends principally on its affinity for water, but 
not altogether ; for it has the ability to coagulate and unite with 
albumen, and to dissolve fibrin. In common with other acids, it 
has a strong affinity for alkaline bases. 

With these properties in view, let us examine its action on the 
teeth. 

The affinity of this acid for water is so energetic that it seems 
even to force its elements to forsake favorite combinations, and to 
unite with each other, that it may be gratified. For example, a 
cork in a bottle of sulphuric acid becomes dark-colored, and is 
really charred. Now a cork, like other wood, is mainly composed 
of carbon, hydrogen, and oxygen — the latter two being in the 
proper proportions to form water. Their affinity for each other, 
quickened by that of the acid for the result of their combination, 
causes them to forsake the carbon, unite with each other to form 
water, and then combine with the acid. The same phenomena 
occur when it acts on animal tissues ; for they are principally 
composed of the above-named elements, with the addition of ni- 
trogen. Accordingly, " black spots are frequently observed in 
the stomachs of those who have swallowed the acid." Now, that 
its slow and prolonged action on the gelatinous portion of the 



DENTAL CARIES. 477 

tooth would result in its carbonization, is a conclusion justified 
both by inference and experiment. But carbonized gelatin is 
"animal charcoal," the color of which is a prominent character- 
istic of " black decay." 

The phosphate of lime in the tooth, which is not the neutral, 
but a subphosphate, is not soluble in sulphuric acid, nor is the acid 
capable of decomposing it, except in the presence of alcohol. It 
follows, then, that this acid does not break down the texture of 
the tooth to the extent that some others do, simply because it can- 
not unite with, or, under ordinary circumstances, decompose the 
principal earthy salt of which it is composed. And here we have 
a second characteristic of " black decay." 

It is now time to inquire whether at all, and if so, by what 
means, and under what circumstances, this acid is brought in con- 
tact with the dental organs. 

Sulphuric, like nitric acid, is frequently administered as a medi- 
cine, and generally with criminal negligence in respect to its ac- 
tion on the teeth. But we cannot regard this as the only or prin- 
cipal source of danger from this acid. If oxygen unites at all 
with sulphur, the tendency, under ordinary circumstances, is to 
the formation of sulphuric acid, as sulphurous acid in the presence 
of moisture is rapidly converted into the sulphuric. The whole 
question, then, is reduced to this : Is sulphur ordinarily present 
in the mouth, and liable there to become oxidized ? 

Albumen is a constituent of mucus, and is contained in many 
articles of food. Sulphur, if not a constituent of, is always united 
with albumen. Its ordinary presence in the mouth is, therefore, 
easily explained. Sulphur and oxygen unite directly, under 
various circumstances, as in the combustion of sulphur, but it is 
probable that the union here is effected by indirect means. Hy- 
drosulphuric acid, or sulphuretted hydrogen, is one of the results 
of the putrefactive decomposition of albuminous substances. The 
breaths of our patients often bear ample testimony to its presence 
in the mouth. Now, the oxygen of the atmosphere rapidly de- 
composes this acid by taking its hydrogen to form water. The 
sulphur is therefore set free, and being in its nascent state, its af- 
finities are increased in energy, and it also unites with oxygen, 
forming sulphurous acid, S0 2 , which in the presence of the water 
of the saliva is rapidly converted into sulphuric acid, or S0 3 . 



478 APPENDIX. 

The quantity of sulphur present in the mouth at any one time 
is very minute, and a great proportion of this is exhaled by the 
breath before it has time to undergo decomposition. And sul- 
phuric acid, as already noticed, has a weaker affinity for the con- 
stituents of the tooth than some others. Hence, " black decay " 
is not so frequently met with as some other varieties. And as 
from the nature of the chemical action the texture of the tooth is 
not so entirely broken up, the carbonized portion protects the 
parts beneath it. This variety of decay, therefore, progresses 
less rapidly than others. 

Hydrochloric Acid. — This acid is also called chlorphydric and 
muriatic acid. It is composed of 35 parts of chlorine, united 
with 1 of hydrogen. Its symbol is HC1. Though its elements 
manifest a strong affinity for each other, yet it is very readily 
decomposed, and many of its chemical manifestions result from 
the action of one or both of its liberated elements. It is on this 
principle the acid attacks metals — being decomposed, the chlorine 
unites with the metal to form a chloride, and the hydrogen es- 
capes with effervescence. 

This acid, like those previously considered, is a caustic poison. 
Its escharotic power depends mainly on its affinity for water, 
which is very active, and on its ability to coagulate albumen. Its 
chemical action is generally inferior to that of the two acids just 
considered. It unites with bases, forming a class of salts called 
hydrochlorates, and sometimes it combines with a salt without 
decomposing it, or being itself decomposed. When concentrated, 
it dissolves animal tissues, but is in this respect far inferior to 
nitric acid. When much diluted, and mixed with dried mucous 
membrane, it dissolves coagulated albumen, fibrin, etc., perform- 
ing to all appearance an artificial digestion. 

A careful observation of these properties will enable us to un- 
derstand the action of this acid on the tooth. 

The carbonate of lime and the acid are mutually decomposed. 
The results are chloride of calcium, water, and carbonic acid. 
The decomposition maybe represented by the following equation: 
CaO,C0 2 + HC1 = CaCl + HO -f C0 2 . 

The carbonic acid, of course, escapes as a gas, and the chloride, 
being very soluble-, is dissolved in the saliva, and thus removed 
from the tooth. 



DENTAL C ABIES. 479 

The phosphate of lime (bone phosphate), though not decom- 
posed by, is highly soluble in hydrochloric acid. It is dissolved 
and is thus removed from the organic portion of the tooth. 

We have seen that this acid, unless highly concentrated, is not 
capable of dissolving the animal portion of the tooth. As this 
concentration is not likely to take place in the mouth, it follows 
that, when hydrochloric acid is the cause of dental caries, the 
earthy portion is dissolved and removed, while the animal por- 
tion principally remains in the carious cavity. And here we have 
the prominent characteristics of a third variety of decay. 
• I have not taken into the account any of the earthy salts con- 
tained in the tooth but the phosphate and carbonate of lime. 
They are present in such small quantities that they exert but 
little influence on any of the chemical actions which we have 
considered. 

Hydrochloric acid is also administered as a medicine, and the 
remarks made on the preceding acids apply equally here. This 
acid is an ingredient of the gastric fluid, and is often present in 
abnormal quantities in the stomach, from which it is thrown into 
the mouth by eructation and vomiting. But we cannot thus ac- 
count satisfactorily for the frequency with which the dental organs 
are evidently injured by this acid. 

Though in its normal state the saliva is alkaline, yet in a va- 
riety of abnormal conditions it contains one or more free acids ; 
and the hydrochloric is one of those most frequently present. It 
often originates, no doubt, in the decomposition of the soluble 
chlorides contained in the saliva and mucus. When the chlorine 
of these is liberated it takes hydrogen from the water of the saliva, 
and this acid is a result of the union. 

But sometimes hydrochloric acid is directly furnished by the 
salivary glands, either as a secretion or an excretion. The system 
may contain just its normal quantity of chlorine, but if there be 
a deficiency of sodium or potassium, the relative excess of chlo- 
rine is converted into hydrochloric acid. In this case the acid 
is secreted. Or, the quantity of potassium and sodium may be 
normal, with an excess of chlorine. The excess will unite as be- 
fore with hydrogen, and the acid will be excreted. At all events, 
this acid is usually found in the mouth when the mucous mem- 



480 APPENDIX. 

brane is inflamed, as well as in patients who indulge in the ex- 
cessive use of salted meats. 

Galvanic currents in the mouth always result in the formation 
of this acid. The chlorides of sodium and potassium present 
in normal mucus and saliva, are decomposed, and their chlorine 
unites with hydrogen derived from the water of the saliva. It 
is on this principle that we frequently find a decayed surface 
around a gold filling which is in close proximity with one of a 
different metal, or with a silver plate or clasp. In such decays, 
the animal portion usually remains while the earthy portion is 
removed, just as would be expected from the prolonged action of 
dilute hydrochloric acid. 

In these observations we have endeavored to set forth the re- 
sults of the ordinary uninterrupted action of these acids on the 
teeth ; and we have seen that they are capable of producing the 
three varieties of decay usually described, though we by no means 
maintain that they are the only agents capable of causing these 
results. Theiractions, and consequently the characteristics of de- 
cay produced by them, are doubtless much modified by circum- 
stances. One of them may be the destructive agent in the com- 
mencement of the caries, and, in process of time, another may be 
developed and exert its specific influence on the same cavity. 
Then the phenomena would of course be complex. Again, it 
should be remembered that a strong affinity for water is a prop- 
erty common to all of them. It is possible, therefore, that car- 
bonization or blackening may result from the action of any of 
them, yet it is by no means probable, at least with nitric acid. 



SECTION B.— DR. CORYDON PALMER'S PLUGGING 
INSTRUMENTS. 

In the following pages are given a description, and the mode of 
using Dr. Palmer's very complete set of plugging instruments. 

They are illustrated in this volume, page 132 (Fig. 54). The 
manner of using them is so explicitly given in these pages, that 



481 



no one of experience in the use of instruments can fail to apply 
them as intended. 

They constitute, altogether, the most perfect set of plugging in- 
struments ever devised. They more nearly meet every case that 
may be presented than anything heretofore used. 

Several instruments, accessory to the set, are here described, 
that are not illustrated in this volume ; they are all, however, very 
valuable, and exactly adapted to the purpose for which they were 
designed. T. 

In the designing of these instruments for the profession, it has 
been my aim to perfect a set that shall enable the operator to 
reach with mallet force any case that may be presented. 

A course of practical experiments dating back to the intro- 
duction of the use of the mallet, has brought me to the present 
designs. 

In conducting the course, my object has been — First, to get the 
best adaptations ; second, to have as few curves as possible ; and 
third, the least number of instruments that will do all the work ; 
and lastly, to have the size and length of each instrument pro- 
portionate to its use. 

There is no one thing that we owe so much to our fellow-prac- 
titioners as to give to each credit for what he does toward the im- 
provement and elevation of our science. 

For my own part, I do not claim entire originality in the forms 
of my instruments. For principles, I am indebted to our worthy 
friend, William H. Atkinson, and for valuable interchanges to 
Charles R. Butler. 

All instruments for mallet forces can be but modifications of the 
foot. My efforts have been to produce a mallet set, to be used in 
their numerical order, that shall indicate a systematic course of 
operating. 

The plugging set consists of thirty -five pieces. Up to No. 16, 
they pertain to the incisors ; and I would especially recommend 
they be used only upon these teeth. The tendency will be to use 
them in every case; but it is too much risk for such fine points. 

Do not pick up the gold upon the point of the instrument and 
hold it in the lamp, as it will quickly destroy the temper. 

31 



482 APPENDIX. 

From No. 17 to 30, the instruments pertain to the bicuspids and 
molars. 

In order to describe the instruments, we must suppose a case : 

Left superior central, anterior approximal surface, cavity, pre- 
pared with fine retaining-pits at each angle of the cervical wall. 

The first three in the order of their arrangement are cutting in- 
struments, and designated by dots to distinguish them from the 
pluggers. The first one is a fine elastic drill, for retaining-pits. 
The second is a fine scoop for clearing the pit. The third is a 
curved side-cut for clearing the last particles from the cavity 
proper. These three instruments are indispensable to the last pre- 
paration of the cavity, and must necessarily be classified with the 
pluggers for the present ; but it is my intention that they shall 
comprise the last and higher numbers of a systematic set of cutting 
instruments to be brought forward in due course of time. 

The two instruments- No. 0, are holders for keeping the gold in 
position until it can be tacked fast. The one with a guard in the 
centre is to be used when no assistant is at hand ; and when held 
between the first and second fingers, the guard is designed to pre- 
vent the fingers from slipping down. The rounded top will be use- 
ful upon which at times to rest the forefinger of the left hand at 
the first joint, and help regain position of the fingers. 

Holders are important instruments, not familiar to all. I would 
draw attention to their use. I feel a particular pride in this one 
new design.. It is purposely short, in order to bring it more easily 
under control ; and having the guard, will enable the operator to 
hold it and the plugger in one hand at the same time. 

The manner of retaining is to place the holder between the first 
and second fingers of the left hand, letting them rest upon the 
guard, and place the plugger between the thumb and forefinger, 
letting the points of the instrument cross in the cavity. 

No. 0, without a guard, is to be used when the help of an assis- 
tant is at hand, and taken up at choice. 

The two holders and the plugger may form at times a useful 
trio. Used without an assistant, the three can beheld in position 
by the left hand, and the stroke given by the right ; or, with assist- 
ant help, the two holders in the left and the plugger in the right 
hand. 



DR. PALMER'S PLUGGING INSTRUMENTS. 483 

The manner of holding the three in one hand is to place the two 
holders in position, as above described, and then add the plugger 
between the thumb and forefinger, in front of the holders, letting 
the points come in position. With assistant help, the two holders 
are held in position as above, and the plugger held in the right 
hand. 

I do not wish to be understood, that the holder is to be used 
throughout an entire operation ; but that in the starting of a fill- 
ing it is indispensable, and at other times useful, as may be indi- 
cated. 

No. 1, Pit Point, is to introduce the first pieces of gold into the 
retaining-pits, and fill all minute cavities upon the labjal surfaces 
where ease of access and direct force can be had. 

No. 2, Small Foot, is to introduce the first pieces of gold after 
the pits are filled, and is to be applied until the gold is made to 
extend from one pit to the other and firmly attached. 

No. 3, Foot, is to add a portion after No. 2, and do the burden 
of the work in filling the cavity even with the edges of the wall. 

No. 4, Foot, is to be used to lay the gold along the cervical wall, 
by letting the heel pass into the cavity, and the point project ob- 
liquely beyond the edge of the wall, so as to carry the gold hard 
upon and perfectly along its whole line. 

No. 5, Curved Foot, is to apply upon the inner surface of the la- 
bial wall, by opening the mouth and applying it direct from the 
Ungual surface. Its curved point will admit of its being brought 
in contact with the wall with less danger of fracture than the plane 
foot. It also has a working point, which may be applied with 
directing force with advantage. 

No. 6, Double Serrated Pit Point, is to carry the gold into the 
apex of the cavity, toward the cutting edge of the tooth. This 
instrument deserves especial notice. It enables the operator to 
carry the gold with mallet force into this part of the cavity with 
ease and certainty. It must be used with careful directing force, 
and can be applied either from the labial or lingual surface. 

No. 7, Slot Plugger, applies in filling the slot, extending from 
the apex of the cavity to and along the line of the cutting edge, 
or wherever slots occur upon the incisors. 

No. 8, Lingual Modeller, applies in modelling up the lingual 



484 APPENDIX. 

ridges of the incisors. Its form enables the operator to hold the 
point to or from him, without danger of impinging upon the ad- 
joining tooth. By opening the mouth, direct force can be given. 
It will be observed that this and several of the other instruments 
are sloped forward in the handle, in order to favor their introduc- 
tion from the lingual surface. 

No. 9, Lingual Mallet Burnisher, applies in the last condensing 
of the gold, along the lingual edges of the cavity. Held at an 
angle bringing it to bear upon one of its sloping faces, it can be 
made to glide along, or bring the point more to bear will follow 
minute lines, as may be desired. 

No. 10, Curved Cervical Modeller, applies in modelling the gold 
at the cervical wall of both the incisors and bicuspids ; is indispen- 
sable for condensing the anterior and posterior surfaces of bicuspid 
fillings. It will be found to reach these surfaces most admirably. 
By applying it as the operation progresses, the approximal sur- 
faces may be modelled into form. 

No. 11, Curved Approximal Modeller, applies upon the approx- 
imal surface of the gold, after the cavity is filled even with the 
edges of the walls, and does all the remainder of the modelling of 
this part of the filling. The gold is to be laid on in flat pieces, 
and the instrument applied both from the labial and lingual sur- 
faces. Its curve enables the operator to pass it through so far 
between the teeth as to easily reach all parts of the approximal 
surface. This instrument forms a marked feature in the set, and 
becomes a great favorite. 

No. 12, Curved Crown Modeller. This instrument applies upon 
the cutting edges of the incisors and the elongation of their crowns, 
and upon all the teeth where direct force is required upon a flat 
surface. 

No. 13, Curved Cusp Modeller. In the operation of elongating 
the crowns of the incisors, the labial and lingual surfaces of the 
gold must be condensed as the operation progresses. Direct force 
is not admissible, and this instrument, held at an angle, meets the 
case. It is also designed to model cusps and fissures. 

No. 14, Curved Model Separator, applies with mallet force in 
effecting a separation between approximal fillings in the incisors, 
and can be introduced from the labial or lingual surfaces, as the 
case may require. 



DR. PALMER'S PLUGGING INSTRUMENTS. 485 

No. 15, Side Curved Sand Separator. Useful in effecting a 
separation of the fillings, same as No. 14. 

No. 16, Curved Sand Burnisher, for the last condensing and 
finish of the filling in the incisors. 

Nos. 17 and 18, Foot Instruments, are the same size upon their 
working faces as Nos. 2, and 3, and are to take their place upon 
the bicuspids and molars. Being designed to do the burden of 
the work, they are made stouter, and with less angle of face, and 
less inner curve. 

No. 19, Foot, is designed to lay the gold upon the cervical walls 
of the bicuspids and molars, by passing the heel into the cavity, 
and letting the point project beyond the edge of the cervical wall. 
Same as the use of No. 4. 

No. 20, Curved Foot, applies upon the thin curved buccal and 
lingual walls of the bicuspids and molars. 

No. 21, Slot P luggers, used wherever slots occur upon the bicus- 
pids and molars. 

No. 22, Double-curved Solder, for the bicuspids and molars, and 
wherever a curved holder is required. 

No. 23, Double-curved Root Plugger, used with directing force 
in the palatal roots of the superior molars, and in all cases where 
large deep root cavities occur. It is the first of a class of eight 
instruments, purposely designed of a larger size than the previous 
numbers, in order to enable the operator at times to grasp the 
instrument firmly in the whole hand, and give directing force. 

No. 24, Double-curved Croze-pointed Plugger, applies in the 
deep angles of the posterior cavities of the inferior bicuspids and 
molars. Used with firm directing force. 

No. 25, Curved Molar Foot r has a working point, and is de- 
signed to introduce all the gold into the inferior central crown 
cavities of the molars. It applies with the use of the holder, by 
first securing the gold in the most deep, distal part of the cavity, 
and then working forward, extending the gold along the sides of 
the cavity, until the centre is passed, and then turning the point 
of the instrument and working backward until the walls of the 
cavity are entirely lined up ; then commence and bring up the 
centre of the filling to finish. This instrument is one of the most 
universally-acting and rapid-working points with which I am ac- 



486 APPENDIX. 

quainted. It admits of being turned to and from the operator, 
and works across the mouth with great advantage. The position 
for the operator for the right inferior molar is back of and above 
the patient. For the left, if the operator is skilled in the use of 
the left hand, he need not change positions ; but if change is re- 
quired, stand at the left side and hold the instrument with firm 
directing force. 

Nos. 26 and 27, Bight and Left Treble-curved Bicuspid Bluggers, 
are designed to introduce the gold into the posterior cavities of 
the inferior bicuspids and molars. The opinion has largely pre- 
vailed that direct mallet force could not be brought to bear upon 
this class of cavities ; but these instruments held in position, will 
give direct forward force, and can be worked across the mouth 
with great satisfaction. They also apply upon the superior bicus- 
pids and molars equally well. 

Nos. 28 and 29, Bight and Left Treble-curved Molar Modellers, 
apply at the posterior cervical walls of the inferior bicuspids and 
molars, and serve to model up all the posterior surface of the 
fillings, enabling the operator to give most direct forward force. 
They reach a point that no other instruments will. Posterior lin- 
gual cusps can be reached with these instruments, and condensed 
upon their posterior and lingual angles, — a point that has been 
hard to reach. They also work across the mouth with great ad- 
vantage, and can be applied to the superior bicuspids and molars 
as well. For applying the instrument to the right inferior molar, 
stand at the back of and above the patient, holding the instrument 
firmly in the whole hand, letting the thumb rest upon the shaft of 
the instrument, and next the cheek, and give tense directing force. 
For the left, stand upon the left side, grasping the instrument 
firmly with the whole hand, letting the fingers go next the cheek, 
and the thumb firm against the shaft, and give tense directing 
force. 

No. 30, Modelling Mallet Burnisher, has a combination of work- 
ing faces. Held at an angle upon one of its sloping faces, it can 
be made to glide along, and lay additional pieces of gold, if de- 
sired ; or, turned more upon its point, will follow fine lines in the 
modelling of cusps and fissures. It will reach the posterior sur- 
faces of the bicuspids and molars, and can be used for the last 



DR. PALMER^ PLUGGING INSTRUMENTS. 487 

hand burnishing of fillings, if desired. Used with the mallet, 
must be grasped firmly in the whole hand, and given directing 
force. 

A word or two in reference to the finish. The instruments are 
purposely finished bright and polished throughout ; because in a 
long course of careful practical experiments, I have found that 
finished in this way they keep better, and are more pleasing to the 
eye. After the brilliancy of the first finish is worn off, they will 
assume a certain dull, silvery surface, which makes them pleasant 
to hold, and they are always clean and presentable. 

The Cases are made from a new design of my own, suited, to 
practice. 

They contain the plugging instruments, four pieces of forceps, 
a foil carrier, and dressing needle ; all of which are new, and es- 
pecially designed and adapted to the mouth by myself. 

No. 1 and No. 2 are punches for the rubber dam, and are so 
formed that they can be applied to put in new holes after the dam 
is adjusted, and thus enable the operator to extend the dam with- 
out the necessity of removing it from the mouth, — a most desirable 
feature in its use. 

The Wedge Cutter is so formed and curved that it can be made 
to reach any point desired, enabling the operator to cut off a wedge 
far back in the mouth, or nip a point along the lingual surfaces 
of the teeth. 

The Wedge Forceps is an entirely new instrument, in size and 
form, pleasant to the hand and eye. Its curve enables the opera- 
tor to pass it far back in the mouth, to reach any point desired, 
and insert or withdraw a wedge, pull off a dipt ligature, or hold 
a piece of wood for porte polish, to apply upon the lingual sur- 
faces, particularly the inferior incisors. Must not be used for 
handling engine bits. 

The Foil Carrier is to be used for picking up the gold, holding 
it in the flame of the spirit-lamp, and carrying it to the mouth. 
May be used also for introducing and removing dressings. Must 
be held between the thumb and forefinger, letting the top of the 
instrument pass over the back of the hand, and not placing the 
hand on the top of the instrument. The points are the most ad- 
vantageously curved for its application to all parts of the mouth. 



488 APPENDIX. 

This foil carrier is designed to be useful in a certain mode of prac- 
tice which I wish to recommend, and that is : during the operation 
of filling, not to lay down the foil carrier, but place it between the 
lips. In this way it is always ready, and no time is lost in hunt- 
ing for it. I must not forget to caution against the danger of 
letting it fall in the face of the patient, and hope that all are 
thoughtful enough to be upon their guard in that respect. I dwell 
a little upon this instrument because it is one of the most impor- 
tant and first looked for when we are ready to fill. It is not in- 
tended to be used as a plugger, and is made purposely light, and 
not with too stiff a spring, so that it can be held as above described, 
without an unpleasant strain upon the lips, and yet tempered and 
stiff enough through the body and points not to bend when used 
to insert or remove a dressing. 

Dressing Needle. — Although this instrument has its more ex- 
tended range of usefulness, it is so inseparable from the opera- 
tion of filling, that I consider the case would be incomplete with- 
out it. 

In the last preparation of a cavity, particularly where there are 
sensitive surfaces, it is desirable to give a dressing before intro- 
ducing a filling. This instrument is the one best suited to the 
purpose. 

In case of classing over exposed nerves, to allay pain, the 
rounded top will be useful to fix the cotton smoothly in position. 

In conclusion, let me say, that the instruments are designed to 
be graceful in form, artistic in finish, proportionate in size and 
length — each one having its particular use — together forming one 
systematic whole.. 



SECTION C.— MALLETS. 



The Electro-magnetic Mallet. — Electro-magnetism has, 
.within the last eight or ten years, been applied and used as a 
motive power for the automatic plugger. 

The plugging instrument operated by this force, though not in 
general use (and perhaps never will be), yet by some it is prized 
very highly, and used with great efficiency. 



MALLETS. 489 

To those unacquainted with electric force, and the appliances 
through which to make it available, this instrument will appear 
complicated and difficult to keep in proper condition, but to those 
familiar with it, it is easily controlled and managed. 

The following extracts from a paper on the electro-magnetic 
mallet, by Dr. Louis Jack, is so directly to the point, that we can 
hardly do better than present them here. 

He says : " The first attempt to take advantage of electro-mag- 
netism for this purpose, it would appear, must be credited to Mr. 
G. F. Green, who first produced, according to his own statements, 
an instrument in which he made use of the power which a heliacal 
coil has to draw within it towards its middle a piece of iron sus- 
pended, or temporarily held at its either end. 

" At each influx of the electrical current the suspended iron 
would fly to the centre with quickness, to be stopped by the 
plugger end, arranged to meet it at that point ; at this moment 
the current was shut off, when the mallet would fly back under 
the force of a spring, only to return again by the recurrent open- 
ing of the circuit. 

"The experiments with this class of electric pluggers have 
proven unsuccessful." 

Mr. Green made other experiments which were equally unsuc- 
cessful. 

Dr. Jack further remarks : " Entirely independent of any 
knowledge of what Mr. Green had been doing in this direction, 
Dr. Bonwill, after watching the working of the armature in the 
magnetic telegraph, conceived, with true inventive talent, the idea 
of utilizing this arrangement, and with the necessary modifica- 
tions and adaptations to employ the force which impacts the style 
upon the paper, in the delivery of the same quick blows upon 
the plugging point. He therefore attached his armature by its 
middle upon a point at a distance relatively far from the electro- 
magnet, making the armature act as a mallet. Thus was secured 
a light and intense blow, and, as the armature moved through a 
small distance, gained the additional quality of rapidity ; a com- 
bination of qualities of the highest importance, rendering his in- 
strument practically efficient. 

"Dr. Bonwill has, from time to time, improved his first instru- 
ment, until we now have from his hands one which has proven 



490 APPENDIX. 

satisfactory in most respects. To him, therefore, we are indebted 
for the first useful electro-magnetic mallet." 

After Dr. Eonwill had arrived at a point in the construction of 
this instrument beyond which he concluded not to go, Dr. Jack 
made some modifications of the instrument, the purport of which 
may be inferred from the following extracts : 

" The objects of this invention are to render the movements 
simpler and more direct than has heretofore been done, with the 
ends in view to produce a sharp and decided impact; to lessen 
the sounds of the movement at both the time of the -impact and 
recoil, and to produce a lighter, cheaper, more convenient, and 
agreeable instrument. 

" The principal feature of this invention consists in the form 
given to the electro-magnet. The core- is made the segment of a 
cylinder, so that when the helices are formed and placed to- 
gether they produce a more or less cylindrical body, leaving 
between them, at the central part, a circular aperture for the 
reception of a small cylinder. 

" This cylinder receives a plugger, which imparts the force of 
the armature upon the plugger, and at the same time permits free- 
dom of movement and gives direction to the armature. 

" There are other improvements depending upon this one, and 
connected therewith, viz. : 

"The form of the armature and its connected parts. 

" The form and arrangement of the circuit-closer. 

" The form and arrangement of the interrupter. 

" The device employed to deaden the recoil. 

" The means of securing the adjustments of the instruments. 

" The best results, and the least discomfort of the patient are 
secured by careful attention to the adjustments. 

" It should be noticed in this connection that the greatest econ- 
omy will be found in having the batteries in clean condition, re- 
plenished to good strength, and the zinc plates kept freely amal- 
gamated." 

In a paper on the electro-magnetic mallet, by Dr. E. T. Darby, 
July, 1875, in speaking of the advantages which the electric 
mallet possesses over all other instruments intended for the pur- 
pose of consolidating gold in the operation of filling teeth, he 
says : " It is purely automatic in its action. 



MALLETS. 



491 



" Its power or force is entirely distinct from anything physical 
or individual, except the will of the operator and the touch of his 
educated finger. 

" No more physical force is required to manage it than would 
guide a pen or hold a pencil. 

" The dentist may stand, or sit in his chair, hour after hour, 
and feel no greater fatigue than would naturally result from re- 
strained position or concentrated thought. 

" Nor is it a labor-saving instrument only, it is a time-saving 
invention also. 

" The length of time required to thoroughly pack the gold in 
most cavities is lessened at least one-half by the aid of the electric 
mallet. 

" Nor is it a time-saving instrument only, it is a pain-saving ap- 
pliance as well. 

" The blow produced by the electric mallet is sharp and quick, 
and does not jar the tooth like the hand mallet, or some other 
automatics. 

" The operator must be skilled in its use, otherwise he will fail 
to accomplish the best results." 

The paragraphs above quoted from the two papers referred to 
on the electric mallet, indicate about an average estimate enter- 
tained by those who have become thoroughly familiar with its use. 

The following illustration shows the present improved form of 
the instrument. 

Fig. 128. 

L 




Description of Electro-magnetic Mallet of Dr. Bonwill. — No. 1, 
E, the horseshoe magnet. M, the brass frame fixed 
firmly to magnet at the top, and holding the arm O, at L, on two 



f-size. 



492 



APPENDIX. 



pivoted screws. R, hard rubber handle, with tool P running 
through it and extending as far to the right under the hammer as 
A. K, slide key, upon which right index finger rests for making 
the circuit, and causing the blows in rapid succession by simply 
pushing slide or key forward. F, the ring through which right 
index finger passes and supports the mallet and prevents falling. 
Thumb rests on tool just below K, and revolves tool in any direc- 
tion. J, an eccentric screw-head to regulate the slide K, to make 
it of very delicate touch. L, posts into which the flexible wires 
from battery go. N, spiral spring inside for throwing the arma- 
ture O back against the check screw-head C, which head also 
opens or closes to control the distance the hammer travels. H, 
screw to regulate strength of spiral spring in N. D, B, and A, 
the automatic brake which controls the number of blows of ham- 
mer. B, screw-head for raising or lowering to permit the tool to 
always keep the right distance to be struck by armature or ham- 
mer. Makes 500 to 3000 blows a minute. Weight eight ounces 
avoirdupois. 

Mallet No. 2. — This is exact size of magnets and the frame. It 
weighs but 6J ounces avoirdupois. 




H, horseshoe magnets, very compact. L, the armature, with- 
out frame or hammer thereon. A, screw to regulate the spring 
of the circuit-breaker. B, posts for attaching flexible wire from 
battery C, automatic brake, which is struck by point of spring 
F, and is always pressing hard thereon. E, screw regulator of 
tool, permitting it to let head of tool project enough to move 



MALLETS. 493 

forward about one-fiftieth of an inch when struck by M on the 

end of brake C. G. handle of hard rubber. 

This is now as complete as can well be made. The first instrument 
weighed one pound. This last is all we could ask in size and 
weight, as well as shape. The handle and the hammer on the 
armature are not shown in the cut of this mallet, nor is the ring. 

They are both run by three cups of smallest size Bonsen Coke 
Battery : i: costs about 15 cents a week to charge them. These are 
the only practical electro-magnetic mallets now in use. As to 
saving of time, it has been claimed by the inventor that he has 
packed one-quarter ounce foil in one hour fifteen minutes. It 
will save three out of four hours, and nearly all the labor. 

Automatic Pluggee foe Engine. — This instrument is the 
invention of Dr. T. L. Buckingham, and. as the caption indicates, 

is operated by the denial engine. Those who have used the in- 
strument and are most familiar with it claim that it possesses every 
available quality for such an appliance. The blow is given by a 
spring, and is entirely under the control of the operator: it is 
regulated by a set screw on the head and a movable collar on the 
hand-piece. The latter can be moved at will during the operation 
of the instrument, regulating the stroke from the strongest required 
to the lightest appreciable touch : or the blows can be suspended 
altogether and the instrument used as a hand plugger, and that, 
too. without stopping the engine. 

The requirements ft delicate operations needing special and pre- 
cise manipulation, are well met by the skilful use of this instru- 
ment. 

The bit-holder is movable, and is drawn back after each blow 
by a small spiral spring attachment. 

The instrument as ordinarily used gives about eighteen hundred 
blows per minute, but the number can be greatly reduced by a 
simple change in the machinery, which can be effected in a few 
moments, and thus the blows reduced to less than one hundred 
per minute. 

The points used in this are such as are in common use with au- 
tomatic mallets. 

A ring accompanies this instrument, which being attached to it 
will aid the operator in holding and directing it while operating. 
It is represented by the following cut ^Fig. 130). 



494 




MATRICES FOR PROXIMAL FILLINGS. 495 

Hyde's Pneumatic Plugger. — This instrument was devised 
and introduced to the profession about 1870. It consists of a 
small cast iron frame, to which is attached a small cylinder, which 
with its piston serves as an air pump ; this is operated by fly and 
drive wheels, which are arranged in the frame and operated by the 
foot. 

To the cylinder is attached a rubber tube about seven feet in 
length ; to this is attached the hand-piece, within which a plunger 
plays ; when in motion this communicates its impulses to the 
plugger. 

As the plugger in the cylinder is driven to and fro, the hammer 
in the hand-piece responds, expending its force upon the socket- 
piece that holds the plugging point. 

The blow is direct and elastic, as the piston or hammer is with- 
drawn the moment the blow is given. 

The rapidity of stroke, as well as the force, is completely under 
the control of the operator. 

This instrument, in the hands of those who have become familiar 
with it, is very efficient and easily operated. 

A modification of this instrument has been made, which consists 
of substituting a rubber ball, about three inches in diameter, for 
the frame, wheels and cylinder ; and the operation is effected by 
working the foot upon the ball. This certainly has the advantage 
of being much more simple. 



SECTION D.— MATRICES FOR PROXIMAL FILLINGS. 

To Dr. Louis Jack belongs the honor of devising and putting 
into practical form the matrices as aids in filling teeth. 

His description of these appliances, and the manner of using 
them, is so concise and complete, that we have, with his consent, 
transferred it almost wholly to these pages. By a careful study 
of the directions here given, almost any one of good manipulative 
ability will be able to use them with good results. T. 



496 APPENDIX. 

"The first step, in case the teeth are in close contact, is to sepa- 
rate them, either by pressure, or, as in so extensive caries as is 
under consideration, by a parallel-sided file ; and from this slight 
separation rapidly and freely open by cutting down the enamel at 
the middle of the space, afterwards increasing somewhat freely 
with the chisel the inner portion of the opening. Another plan I 
sometimes pursue, where no fracture of the masticating plate has 
occurred, is to pass a small five-sided drill until it fails to meet 
with resistance, increasing by a larger drill ; and from these two 
half circles I cut in either direction with suitable chisels by care- 
fully splitting down the enamel, — first the masticating portion, — 
and continuing until a free space is secured on the inner side; then 
more carefully opening towards the buccal division, until a slight 
space is made at this point. The file may be used at this stage to 
further open the space, and in bringing the surfaces into proper 
shape and smoothness. When the cavities are so large as is as- 
sumed above, there will usually be found so much disorganization 
of the enamel as to render necessary so much cutting to procure a 
healthy surface as will open a space abundantly large for the sub- 
sequent work. If more is needed, it is secured by wedging; in 
any case a separation as large at the lower part as a No. 7 Froid 
file, and at the cervical part as a No. 3, is easily secured. The 
buccal space should be but slightly wedge-shaped, and somewhat 
smaller than the palatal, for reasons which will appear in the 
proper place. 

" After removing the softer caries, the walls of the cavity are 
prepared for the reception of the filling ; the overhanging masti- 
cating plate being first cut away in a circular form on a line with 
the bottom or pulp wall, so that by direct approach every part 
of the cavity is accessible to slightly curved or even straight in- 
struments. This opens the whole cavity to view. The instru- 
ment best adapted for this purpose is the gouge-shaped chisel, 
which cuts with exceeding keenness, and produces the form de- 
sired at this part. The removal of this portion of the enamel is 
an important and indispensable step in the improvement I am 
pursuing. It is practiced by the better operators to a somewhat 
less degree, and is in many cases an advantage to the organ. No 
other argument to defend this course may be used than that in 



MATRICES FOE PROXIMAL FILLINGS. 497 

these fillings, so difficult of execution, everything subservient to 
better performance must be followed out which is not injurious to 
the strength and preservation of the organ. It will often prove 
true here, as elsewhere in surgery, that something must be taken 
to save the remainder. 

" The cervical wall is now cut at a right angle to the proximal 
surface, taking care to remove from the surface of the tooth be- 
neath the gum any half-decomposed enamel which may be pres- 
ent at this part. No retaining-groove or pits are needed on this 
wall. 

" The buccal and palatal walls are next smoothly cut, and on 
the side of each, where they have sufficient strength, a shallow, 
round-bottomed groove is made the whole length, and terminat- 
ing at the very surface of the masticating plate of enamel. The 
outer retaining-groove should be near the margin, to avoid any 
approach to the pulp ; the inner one should be nearer the bottom 
of the cavity, so that, in the subsequent cutting away of a por- 
tion of the palatal wall in the finishing process, the hold of the 
gold may not be obliterated. The instruments best adapted for 
this grooving are made by filing a straight point quite round and 
small, then bending at a suitable angle, and shaping so as to 
have the edge at the inner side of the curve. Instruments of 
this form are better adapted for cutting the hard dentine and 
enamel than any others, for the reasons that they may be made 
harder than usual without danger of breakage ; they cut with 
more keenness, do not chatter, leave the surface without sharp 
lines, and, in grooving, each cut follows the last with certainty. 
They are directly reverse in form to the hoes and excavators in 
general use. 

" The pulp-wall of the cavity is not altered in the form it pre- 
sents after the removal of the caries. 

" The next and very important step is to remove the sharp corners 
of the mouth of the cavity, and at every part well polish it with 
pumice-stone ; this facilitates the passage of the gold over the 
surface, and the perfect contact of the foil with every part. This 
polishing is rapidly done by rotating a piece of boxwood armed 
with pulverized pumice. 

" Selection is now made of one of the appliances figured below,, 

32 



498 APPENDIX. 

which are intended to give form to the outer surface of the filling, 
and are called matrices for this reason. These little affairs are 
made of a variety of shapes, sizes, and thickness. They are 
formed of slightly wedge-shaped pieces of steel, 
and are, as the cut designates, hollowed out at their 
thicker edge, which depression terminates at the 
thinner edge. At the part of the depression de- 
signed to give shape to the buccal edge of the filling the cut is 
generally abrupt and deep ; at the inner portion it is more shal- 
low and more inclined. It will be observed that the depression 
widens as it passes toward the thinner edge to follow the usual 
form of proximal cavities.* The lower and thin edge is rounded, 
to outline the curved margin of the cervical wall, and to effect 
pressure upon either the gum or the appliances used to stop the 
escape of mucus and blood from this tissue. 

" The plane parts of the face are file-cut or coarsely draw-filed. 
The reverse side, represented in Fig. 131, and which for con- 
venience of description is divided into three sections, is, in most 
cases, plane and smooth, excepting at the 
section c, which is file-cut. It is often 
a ' — ~/ £~~~^^D necessary to have this side in two sur- 

c. Ss«~~^7 faces, one section, a, parallel with the 

plane parts of the face, and from this 

point inclining to a thin edge. A very desirable form is to have 

section c bent backwards to follow the incline of the proximate 

tooth beneath the gum. At each end a square cut is made to fit 

1 the plier ends represented at Fig. 133. After 

f~ being formed they are protected from oxidation, 

m heated to redness, plunged in the cold bath, and 

temper drawn to near blueness; after polishing 
the depression they will be ready for use. Quite a number of pairs 
are necessary to meet the requirements of the differing cases, but 
for the ordinary-sized simple proximal cavities a dozen pairs, 
varying in width, in thickness, and in size of depression, are all 
that I have found necessary. Fig. 131 represents the largest 

* In Fig. 131 the boundary of the right end of the depression should be 
similar to the other end. 



MATRICES FOR PROXIMAL FILLINGS. 499 

size required, those in most use not being more than from one- 
half to two-thirds this width and thickness. The character of 
these modifications will depend somewhat upon the desired end. 
since either a flat contour or excessively convex surface may be 
produced at the pleasure of the operator, or to suit the needs of 
the individual operation, by varying the form and depth of the 
depression. It is also occasionally necessary to have a matrix 
of unusual form to meet special cases, where the space is ex- 
tremely great, or where, from the fracture of the outer plate of 
enamel, a steel one will not remain in position ; for this purpose 
I have fouod hard boxwood to answer quite well. Silver, also, 
in such cases, will occasionally be found useful. I sometimes 
take an impression of the immediate part to assist me in the 
fabrication of a suitable appliance. I have also made double- 
faced ones, which are so formed as on one adjustment to allow 
both cavities to be filled. For isolated teeth, having large pos- 
terior cavities, a ring of silver may be used, carryingoutthe same 
principle in forming the portion which bounds the cavity. I have 
used the same plan in buccal cavities. 

"The selected matrix should, at the convex edge, be a little 
thinner than the space between the teeth at their closest part by 
the gum ; it should pass above the edge of the cervical wall, and 
should conform at this part to the contour of the tooth ; the 
lower and thicker edge should reach nearly to the masticating 
surface, and this edge should not entirely fill the lower part of 
the space; above all, the depression at every part of its border 
should extend slightly beyond the edge of the civity. 

"After having secured the cervical part of the case from the 
encroachment of moisture, by means of the rubber dam, or, when 
this is not applicable, wedges of wood, little rings of india-rub- 
ber, the string-dam, short pieces of waxed twine, of such size as 
to remain firmly in place when drawn between the teeth, the ap- 
plication of dilute chloride of zinc, etc., or a combination of two 
or more of these means, the matrix is taken up in the pliers 
(Fig. 133) and pushed upward until it presses upon the gum or 
the appliances, and until it impinges tightly between the teeth. 
It is now wedged firmly against the tooth to be operated upon 
with little boxwood wedges; these secure it in place during the 



500 APPENDIX. 

packing. It is well usually to insert two wedges, one from the 
buccal side between the teeth near the margin of the gums, and 
one from the palatine or lingual side, nearer the masticating 
surface of the teeth than the margin of the gum ; thus the ma- 
trix will be firmly keyed to its proper position. When the 
matrix passes up to the proper point, the wedging towards the 
cavity throws the lower edge against and somewhat beneath the 
projecting swell of enamel of the neighboring tooth, which adds 
to the security. However tightly the matrix may fit between 
the teeth, it will not, frequently, retain its fixedness unless se- 
curely wedged. Boxwood answers for this purpose better than 
any substance I have employed, for the reason that it is so hard 
as to be unyielding, and on this account also does not require to 
be more than pushed into the space. The wedges should be made 
to conform in size and shape to the space they are intended to 
occupy, in order that they may the more firmly retain their po- 
sition when inserted. Moistening them with a solution of gum 
sandarac or mastic adds much to their security in position after 
they are introduced. The pliers (Fig. 133) are adapted to their 
introduction. 

" In case the adjoining teeth are not in contact it is always neces- 
sary to introduce a wedge between them, to give greater firmness 
to the teeth and less discomfort to the patient. In all large cav- 
ities I fix the matrix previous to introducing the napkins. Where 
the rubber dam is required, it precedes this appliance, which may 
aid in keeping the rubber in place. 

" For the small cases, the drying is done first, the napkins ap- 
plied, and a hard rope of bibulous paper is passed against the gum, 
followed by the matrix. Fig. 134 represents the appearance of the 
parts at this stage, except the wedges, which are 
not shown. When the cavity is now examined, 
it will be found to present an open mouth, formed 
by its curved lower edge of enamel, and by the 
boundary of the matrix, through which funnel- 
shaped opening every part of the space is easily 
seen and directly touched. The case is now ready for the recep- 
tion of gold. 

" I use for the upper half or more of the filling, ribbons of Nos. 




MATRICES FOR PROXIMAL FILLINGS. 501 

4, 5, or 6, of non-cohesive gold, not annealed. These ribbons are 
made of one-fourth to whole sheets of foil, depending on the size 
of the space, and then folded into blocks, varied in length by the 
requirements of the case. For the lower third I prefer rolled 
gold of No. 20 to 30, of the most adhesive character, and aunealed. 
I also use for this part in many cases ' Eureka gold filling,' No. 
15, with the greatest advantage, taking up one or more of the 
shreds, and working them in wherever needed. The first block 
or mat is passed up toward the outer border, until it reaches the 
cervical wall, w r hen the lower end is pushed into place, and fast- 
ened by pressure into the upper part of the retaining-groove. The 
second piece is secured in the same manner in the inner or palatal 
groove ; a further piece is forced between the two, and directly 
against the cervical wall. When a sufficiency of gold is placed 
upon these parts to save the tooth from contact of the points, 
the gold is securely malleted against the walls at all points, pay- 
ing particular attention to the junction of the tooth with the ma- 
trix. In this way I proceed, successively introducing and mallet- 
ing, until the cavity is two-thirds filled, not hastening further at 
any point, unless the assurance is reached that the gold is per- 
fectly consolidated. At this point I commence and continue the 
employment of heavy gold, the first pieces of which should be well 
fixed in the gold previously introduced at the parts over the re- 
taining-grooves, and also worked well into the foundation. It is 
now a simple matter to fill up the remainder with quickness. 

" In case there should happen to be an encroachment by moisture 
at or near the close of the packing, the gold may be made smooth 
on the exposed surface, dried, and the latter part inserted, with 
all the characteristics of a separated filling. The form of the last 
third is such that, if inserted with dryness, no portion can escape. 
The matrix should now be removed. 

" It will be found, if the selection and adjustment of the matrix 
has been correct, that very little filing and cutting down of the 
plug will be required, and, in case the packing has been carefully 
performed, that the gold will be solidly condensed at every part. 
It will also be noticed that, while the gold is solid, it will not 
have become hardened in temper on the proximal surface, but 
yields laterally under the burnisher, not unlike lead or tin. 



502 APPENDIX. 

" I must at this point call attention to the importance of the 
adaptation of the filling material to the cervical wall, which it re- 
quires no words to show will be secured by this method. There can 
hardly be a question that the general failure of proximal fillings 
is due to one or both of two causes, — the imperfect preparation of 
the cavity, and the want of solidity and adaptation of the gold at 
this part. When the filling extends to the gum or beneath it, and- 
the teeth are not permitted to come into apposition here, this 
portion of the tooth, when well protected, is least liable to decay, 
08 this is not the place where caries usually commences. And when 
the filling reaches to the cementum, the recurrence of caries is still 
less to be apprehended, since it is a clearly established, but ap- 
parently overlooked, principle that this structure is the least lia- 
ble of the dental tissues to destruction. It will be noticed how 
seldom failures occur along the cervical edge of gutta-percha fill- 
ings, even when carelessly performed. These considerations have 
been forcing many to seek for better means of securing adapta- 
tion, solidity, and smoothness at this part. 

"The instruments for introducing the filling are of simple forms 
and direct action, but they should be in fine condition, — that is, 
the points should be well serrated, and sharp. The only important 
modification needed are some pairs of mated pluggers, formed as 
at Fig. 135, in which one side of the edge is considerably longer 
than the other, which longer side, in malleting, is con- 
' stantly kept against the matrix ; this effects the greatest 
pressure upon the margins, and secures with positiveness 
the perfect fulness and the proper consolidation of the 
gold at these parts. Several sizes and varied curves of 
this point are required. 

" The finishing of the case is not different from the usual 
course pursued. In my own practice I open still further 
the inner portion of the space, which is easily done with 
chisels and suitable files. The peculiar form of the de- 
pression in the matrix produces a space which is considerably 
greater on the inner side, and which may be increased at pleasure. 
In many cases, where the tendency to caries is very great, I chisel 
quite freely from the inner plates of enamel, doing this after both 
the adjoining fillings are inserted, cutting down both gold and 




MATRICES FOR PROXIMAL FILLINGS. 



503 



Fig. 136. 



eDamel together, allowing the fillings to touch only at the promi- 
nent outer part. The result is then an imitation of the exceed- 
ingly oval bicuspid, the immunity from decay of which all must 
have seen examples. 

"Fig. 136 represents a transverse section of two 
cases at a point immediately above the grinding 
surface, which exhibits the outline of the form of 
the cavity and finished surface of the gold. 

"In full confidence, founded on considerable 
trial, I claim that this method of filling large distal-proximal cav- 
ities overcomes several of the chief difficulties and deficiencies 
hitherto experienced, as well as enables greater facility of per- 
formance, and the securing of excellent results." 




INDE I. 



Abrasion, chemical, 38. 

Actual cautery, 307. 

Accidents in the extraction of teeth, 433. 

Adaptability, 79. 

Alveolar abscess, 339. 

treatment of, 344. 
Amalgam, 91. 
Anaesthetics, 455. 
Appendix, 469. 

Appliances for examination, 1 56. 
Arsenious acid, 281, 308. 

application of, 310. 
Atrophy, 30. 

Attachment of artificial crown, 359. 
Automatic plugger for engine, 494. 

Block filling, 194. 
Breaking the teeth, 447. 
Bur drills, 101,111. 

Caries of the teeth, 43, 475. 

predisposing causes, 52. 

exciting causes, 57. 

consequences of, 66. 

treatment of, 68. 

comparative liability to, 64. 
Caustics, alkaline, 284. 
Chloride of zinc, 280. 
Chloroform, 457. 

Classification of cavities of decay, 217. 
Conditions to be observed in the extraction of teeth, 428. 
Congelation, 462. 



506 INDEX. 

Cohesive gold foil, 227. 

Crystal or sponge gold, 89, 231, 209. 

Creosote and carbolic acid, 279. 

Cylinder filling, 194. 

Cobalt, 313. 

Dental periostitis, 331. 

treatment of, 335. 
Dental caries, 43, 446. 
Denuding of the teeth, 36. 
Deposits on the teeth, 18. 

points of, 20. 
Destruction of the pulp, 302. 
Dislocation of the inferior maxilla, 450. 
Drills, 101. 
Drill stocks, 106. 



Electro-magnetic mallet, 491. 

Elevators, 400. 

Ether, 455. 

Examination of decays, 155. 

Excavators, 114. 

manufacture of, 119. 
Exostosis, 33. 
Exposed pulps, 287. 

treatment of, 289. 

destruction of, 302. 
Exclusion of moisture, 172. 
Extraction of teeth, 374, 406, 426. 
Extraction of roots, 414. 
Extracting instruments, 383. 
Extraction by electro-magnetism, 465. 
Extraction of the inferior incisors, 418. 



Filling instruments, 121. 
Filling teeth, 154. 

examination of, 155. 

opening cavities, 158. 

removal of decay, 160. 
Filling by classes and modifications, 219. 

with foil, 227. 
Filling large cavities on the labial surfaces of superior incisors, 265. 



INDEX. 507 



Filling pulp-cavities and canals, 315. 

Finishing fillings, 213. 

Fitting the crown, 357. 

Forming cavities, 164. 

Forming blocks, 195. 

Forceps, 388. 

Fracture of the alveolus, 451. 

General remarks on filling, 74. 
Gold, 86. 
Green tartar, 25. 

its origin, 26. 

treatment of, 28. 
Gum lancet, 403. 

Hyde's pneumatic plugger, 595. 
Heavy cutting-instruments, 99. 
Hemorrhage, 434. 

treatment of, 443. 
Hooks, 401. 

Inferior bicuspids, 420. 
Inferior cuspids, extraction of, 419. 
Inferior third molars, extraction of, 425. 
Inferior molars, extraction of, 421. 
Instruments for filling, 99. 
Introducing the filling, 189. 
Introducing the blocks, 198. 
Introduction, 17. 
Indications for extraction, 380. 
Irregularity of the teeth, 28. 
effects of, 30. 

Laceration of the gums, 446. 
Lead for filling, 81. 
Local anaesthesia, 462. 

Matrices, 495. 

Manufacture of excavators, 119. 

Materials for filling, 78. 

properties of, 78. 

non-metallic, 95. 



508 INDEX. 

Metallic pivots, 363. 
Mode of using the file, 137. 

Necrosis of the teeth, 40. 

causes of, 42. 
Nitrate of silver, 278. 
Nitrous oxide, 459. 
Nitric acid, 474. 

Opening cavities, 158. 
Oxychloride of zinc, 94. 

Palmer's plugging instrument, 480. 

Pathological conditions, 270. 

Pellets for filling, 201. 

Pivot teeth, 353. 

Platinum, 85. 

Potential cautery, 308. 

Predisposing causes of caries, 52. 

Preparations of gold, 88. 

Preparing the teeth and roots for filling, 322. 

Removal of decay, 160. 
Removal of the third molar, 415. 
Removal of a wrong tooth, 448. 
Rubber-dam appliances, 177. 

Saliva pump, 175. 

Screw, 401. 

Separation of the teeth, 142. 

Sensitive dentine, 271. 

Silver, 84. 

Superior cuspids, extraction of, 408. 

Superior bicuspids, extraction of, 409. 

Superior molars, 415. 

Syncope, 452. 

Tannin or tannic acid, 277. 
Tartar, 18. 

origin of, 19. 

points of deposit, 20. 



INDEX. 509 

Tartar, effects of, 22. 

method of removing, 23. 
Terchlorideofgold, 281. 
The key. 384. 

The method of lancing the gums, 404. 
The mallet, 206. 
The file, 134. 

use of, 137. 
The palatal portion of the crown broken away, leaving the outer portion 

standing — pulp not exposed, 260. 
The clamps, 179. 
Tin, 81. 

Treatment of caries, 68. 
Treatment of exposed pulp, 289. 
Treatment of sensitive dentine, 274. 












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